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There is limited research exploring menstruation in transgender and gender diverse (TGD) populations, and studies have primarily examined the relationship between menstruation and gender congruence. Findings revealed menstruating TGD people experienced distress related to decreased gender congruence (Eisenberg et al., 2021), and 88% of TGD people expressed interest in menstrual suppression to manage the distress (Schwartz et al., 2022). By contrast, Lowik (2020) highlighted a transfeminine person who wished to menstruate to achieve womanhood and commented on the “bloodless period” (i.e., menstrual-like symptoms in the absence of bleeding) upon receiving gender-affirming hormone therapy. To the author’s knowledge, there is no published research focused on menstruation in the transfeminine population.
This study was the first study to capture the lived menstrual experiences of transfeminine people and explore the concept of a “bloodless period” among ten White transfeminine adults in the United States. A critical (Horkheimer, 1975) queer (Gamson, 2000; Wozolek, 2019) interpretative phenomenological analysis (Smith and Osborn, 2008) was applied, and the results revealed five themes: (1) emotionally and physically adjusting to GAHT, (2) learning to engage in menstrual management in daily life, (3) menstrual symptoms support positive gender congruence, (4) need for increased transfeminine inclusivity, and (5) unlearning binary and sex-negative social messages.
Advisor: Dena M. Abbot

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University of Nebraska - Lincoln DigitalCommons@University of Nebraska - Lincoln College of Education and Human Sciences: Dissertations, Theses, and Student Research Education and Human Sciences, College of (CEHS) 4-2024 The Bloodless Period: A Transfeminine Experience Rin Nguyen University of Nebraska-Lincoln, knguyen21@huskers.unl.edu Follow this and additional works at: https://digitalcommons.unl.edu/cehsdiss  Part of the Counseling Psychology Commons, Educational Psychology Commons, Gender and Sexuality Commons, Lesbian, Gay, Bisexual, and Transgender Studies Commons, and the Reproductive and Urinary Physiology Commons Nguyen, Rin, "The Bloodless Period: A Transfeminine Experience" (2024). College of Education and Human Sciences: Dissertations, Theses, and Student Research. 433. https://digitalcommons.unl.edu/cehsdiss/433 This Article is brought to you for free and open access by the Education and Human Sciences, College of (CEHS) at DigitalCommons@University of Nebraska - Lincoln. It has been accepted for inclusion in College of Education and Human Sciences: Dissertations, Theses, and Student Research by an authorized administrator of DigitalCommons@University of Nebraska - Lincoln. i  THE BLOODLESS PERIOD: A TRANSFEMININE EXPERIENCE  by  Rin Nguyen   A THESIS   Presented to the Faculty of The Graduate College at the University of Nebraska In Partial Fulfillment of Requirements For the Degree of Master of Arts  Major: Educational Psychology  Under the Supervision of Professor Dena M. Abbott  Lincoln, Nebraska  April, 2024  ii  THE BLOODLESS PERIOD: A TRANSFEMININE EXPERIENCE Rin Nguyen, M.A. University of Nebraska, 2024 Advisor: Dena M. Abbott  There is limited research exploring menstruation in transgender and gender diverse (TGD) populations, and studies have primarily examined the relationship between menstruation and gender congruence. Findings revealed menstruating TGD people experienced distress related to decreased gender congruence (Eisenberg et al., 2021), and 88% of TGD people expressed interest in menstrual suppression to manage the distress (Schwartz et al., 2022). By contrast, Lowik (2020) highlighted a transfeminine person who wished to menstruate to achieve womanhood and commented on the “bloodless period” (i.e., menstrual-like symptoms in the absence of bleeding) upon receiving gender-affirming hormone therapy. To the author’s knowledge, there is no published research focused on menstruation in the transfeminine population.  This study was the first study to capture the lived menstrual experiences of transfeminine people and explore the concept of a “bloodless period” among ten White transfeminine adults in the United States. A critical (Horkheimer, 1975) queer (Gamson, 2000; Wozolek, 2019) interpretative phenomenological analysis (Smith & Osborn, 2008) was applied, and the results revealed five themes: (1) emotionally and physically adjusting to GAHT, (2) learning to engage in menstrual management in daily life, (3) menstrual symptoms support positive gender congruence, (4) need for increased transfeminine inclusivity, and (5) unlearning binary and sex-negative social messages.  iii  TABLE OF CONTENTS Tile Page .............................................................................................................................. i Abstract ............................................................................................................................... ii Table of Contents ............................................................................................................... iii The Bloodless Period: A Transfeminine Experience ...........................................................1 Menstruation ........................................................................................................................2 Attitudes Toward and Experiences of Menstruation ....................................................... 2 Development of Attitudes Toward Menstruation ............................................................ 6 Menstrual Management .......................................................................................................7 Menstruation Management and Gender Congruence..................................................... 9 Menstruation Management Among TGD People .......................................................... 11 Current Study .....................................................................................................................13 Method ...............................................................................................................................13 Researcher-as-Instrument Statement ............................................................................ 15 Participants .................................................................................................................... 16 Sources of Data ............................................................................................................. 21 Data Analysis .....................................................................................................................22 Results ................................................................................................................................24 Discussion ..........................................................................................................................40 Integration with previous literature ............................................................................... 41 Implications for training and practice ........................................................................... 44 Limitations and Future Directions ................................................................................ 46 iv  Conclusion .................................................................................................................... 49 References ..........................................................................................................................50 APPENDIX A ....................................................................................................................71 APPENDIX B ....................................................................................................................75 APPENDIX C ....................................................................................................................78 APPENDIX D ....................................................................................................................79 APPENDIX E ....................................................................................................................81 APPENDIX F.....................................................................................................................83 APPENDIX G ....................................................................................................................86 APPENDIX H ....................................................................................................................92       1  The Bloodless Period: A Transfeminine Experience Menstruation is defined as “the monthly shedding of the lining of [the] uterus” (Cleveland Clinic, 2019, para. 2). Although menstruation is often considered in the context of the experiences of cisgender women (Brantelid et al., 2014; DeMaria et al., 2020; Donmall, 2013; Jackson & Falmagne, 2013; Mason et al., 2013), many scholars have begun to critique the idea of menstruation as an experience unique to women and a mark of womanhood. Scholars have promoted a more feminist and gender-inclusive conceptualization of menstruation and have acknowledged that not all women menstruate and not all who menstruate are women (Frank, 2020; McHugh, 2020; Rydström, 2020). This contemporary view on menstruation is particularly important as it plays a key role in gender congruence (i.e., "the feeling of harmony in [a person’s] gender”; Gender Spectrum, 2019, para. 13) for both cisgender women (Brantelid et al., 2014; Brown, 2007; Newton & Hoggart, 2015; Juyal et al., 2012) and transgender and gender diverse (TGD) people (Cavanaugh & Ladd, 2017; Chrisler et al., 2016; Eisenberg et al., 2021; Frank, 2020).  For the purpose of the study, TGD is an umbrella term used to describe people whose gender identity does not align with their sex assigned at birth (GLADD, 2021; National Center for Transgender Equality, 2016). Research on menstruation within the TGD community remains severely understudied, even more so among transfeminine people (Frank, 2020; Lowik, 2020), or any person whose sex was assigned male-at-birth and whose gender identity is feminine of center (LGBTQ Nation, 2022; UCSF Gender Affirming Health Program, 2016). Therefore, using a critical (Horkheimer, 1975) queer (Gamson, 2000; Wozolek, 2019) interpretative phenomenological analysis (IPA; Smith &   2  Osborn, 2008) approach, the current study centered on menstruation as it applied to transfeminine people and examined the unique experience of a “bloodless period” and how it related to gender congruence. Menstruation  Menstruation refers to a process in which “blood and tissue from [the] uterus come out of [the] vagina” (Planned Parenthood, 2020, para. 1). Menstruation is part of the “reproductive system and prepares [the] body for a possible pregnancy. It is also called a period, menses or cycle” (Cleveland Clinic, 2019, para. 1). Though this definition utilized language that is inclusive of people of all genders with uteruses, many definitions still denote menstruation as an experience that is exclusive to cisgender women (Mayo Clinic Staff, 2021; MedicinePlus, 2022). The term cisgender is used to describe people whose gender identity aligns with their sex-assigned-at-birth (e.g., cisgender women were assigned female-at-birth and identify as women; Merriam-Webster, 2022.) Historically, conversations surrounding menstruation have been reserved within the spheres of cisgender women and have primarily been associated with the process of achieving womanhood (Juyal et al., 2012; Wong, 2011). Attitudes Toward and Experiences of Menstruation Conversations about menstruation have long persisted throughout history and varied interpretations of menstruation have developed within different cultures and societies. For example, in Native American cultures, people were often seen as being most powerful, physically and spiritually, when they were menstruating. Menstruation was also said to carry healing energies by the villagers of a Dagara tribe in West Africa and was depicted as a symbol of life by the Pygmies in the Congo (Owen, 2009).   3  Likewise, Brown (2007) noted how cisgender women often viewed menstruation as an empowering moment that affirmed their womanhood and power to create life and allowed them to feel connected with their bodies. Similar studies have also observed increased positive attitudes toward menstruation for cisgender women who also reported positive feelings toward their bodies (Chrisler et al., 2015; Rembeck et al., 2006). Finally, some studies have found that the majority of cisgender women held positive attitudes toward menstruation within countries such as Nigeria (Moronkola, 2006) and India (Hoerster et al., 2003), though these positive attitudes were often associated with having more medical-based education about menstruation.  Positive portrayals of menstruation were present throughout a variety of societies. However, the provided examples constituted the bulk of the available texts that discussed positive experiences and attitudes toward menstruation. In contrast, menstruation has been well-established as a topic of stigma (Johnston-Robledo & Chrisler, 2020; Kowalski & Chapple, 2000; MacLean et al., 2020), and negative attitudes towards menstruation were significantly more common than positive ones (Johnston-Robledo & Chrisler, 2020). Throughout their lifespan, cisgender women received many negative messages regarding menstruation from their mothers (Anson, 1999; Costos et al., 2002), male partners (Peranovic & Bentley, 2017), through illustrations of menstruation via advertisements (Simes & Berg, 2001), and other sources of media (Eswi et al., 2012). These negative messages were often internalized as numerous studies that examined cisgender women’s attitudes toward menstruation revealed overwhelmingly negative attitudes toward menstruation (Allen et al., 2011; Andrist, Hoyt, et al., 2004; Brantelid et al., 2014). These negative attitudes were pervasive with cisgender women using terms   4  such as disgusting (Brantelid et al., 2014; Donmall, 2013), filthy (Koutroulis, 2001), messy (Donmall, 2013; Koutroulis, 2001; Newton & Hoggart, 2015), and smelly (Burrows & Johnson, 2005; Koutroulis, 2001) to describe their menstruation. Cisgender women’s negative attitudes toward menstruation were associated with negative experiences of menstruation (Marván & Chrisler, 2018). Overwhelmingly, cisgender women reported having negative experiences of menstruation (Aflaq & Jami, 2012; DeMaria et al., 2020), even when they were specifically asked to discuss positive experiences associated with their menstruation (Fahs, 2020). The experiences of menstrual symptoms were especially viewed as a negative component of menstruation. The vast majority of cisgender women reported experiencing at least one menstrual symptom (Schoep et al., 2019), with menstrual pains being one of the most commonly reported (Grandi et al., 2012; Iacovides et al., 2014; Schoep et al., 2019; Yamamoto et al., 2009). Menstrual pain frequently impacted cisgender women’s ability to take on daily tasks (Grandi et al., 2012; Schoep et al., 2019) and reduced their overall quality of life (Iacovides et al., 2014). In turn, these negative experiences further contributed to cisgender women’s negative attitudes toward menstruation (Hewison & van den Akker, 1996). In contrast to the literature on cisgender women’s experiences of and attitudes towards menstruation, there is extremely limited research on menstruation within the TGD community, especially those that focused on attitudes toward menstruation. TGD identities have only been recently introduced and included in conversations around menstruation (Cavanaugh & Ladd, 2017; Chrisler et al., 2016), and most studies were centered on medical considerations related to menstruation among TGD people (Ahmad   5  & Leinung, 2017; Hodax et al., 2020; Schwartz et al., 2022). Research focused on TGD people’s experiences of menstruation is limited to about a dozen published studies, and most of this research has been conducted since 2016 (Cavanaugh & Ladd, 2017; Chrisler et al., 2016). Moreover, to the author’s knowledge, only two published studies have attempted to include transfeminine people (Frank, 2020; Lowik, 2020). These studies were ultimately only able to recruit one or two transfeminine persons (Frank, 2020; Lowik, 2020), and one study made the decision to exclude the data of the transfeminine participants from the analysis (Frank, 2020). This lack of research demonstrated an immediate need to better understand menstruation within the TGD community and even more so within the transfeminine population.   Of the available literature on menstruation within the TGD population, Chrisler and colleagues (2016) published one of the only known studies that focused on the examination of the attitudes of TGD people toward menstruation. In a sample of transmasculine people, some participants expressed uncertainty about whether menstruation was a topic they felt comfortable discussing. Transmasculine participants also noted distress and discomfort with discussing menstruation. Comparatively, transmasculine people still often expressed similar negative attitudes toward menstruation as cisgender women and described menstruation as annoying (Chrisler et al., 2016). Given the limited background, it is important that menstruation within the TGD community is further explored to understand how TGD people’s experiences and attitudes are similar to or different from those of cisgender women.    6  Development of Attitudes Toward Menstruation  For cisgender women, mothers have been shown to be the main source of information about and support for menstruation (Aflaq & Jami, 2012; Brantelid et al., 2014; Rembeck et al., 2006) followed by friends (Brantelid et al., 2014). Mothers also played a key role in the development of cisgender women’s attitudes toward menstruation (Aflaq & Jami, 2012; Brantelid et al., 2014; Donmall, 2013; Marván & Molina-Abolnik, 2012; Stoltzman, 1986). Cisgender female adolescents expressed more positive attitudes toward menstruation when mothers approached the topic of menstruation with a positive attitude (Brantelid et al., 2014). Additionally, cisgender women reported negative perceptions and experiences of menstruation when their mothers did not engage in conversations around menstruation. Cisgender women who were given positive descriptions of menstruation also had increased positive attitudes toward menstruation in a study on priming (Rose et al., 2008). Nonetheless, these conversations did not always occur as many mothers expressed a lack of education and felt incompetent in discussing menstruation with their daughters (Aflaq & Jami, 2012). Similar to cisgender women, a study by Frank (2020) demonstrated that TGD people also saw mothers as an important source of information and support for menstruation. TGD people reported a similar increase in positive attitudes toward menstruation when their mothers took a menstrual-positive approach. However, these conversations were described as awkward, uncomfortable, or negative. Fortunately, despite the associated distress and discomfort, the vast majority of transmasculine people still noted a willingness to discuss menstruation with supportive friends. Access to   7  supportive friends, in turn, fostered positive attitudes toward menstruation (Chrisler et al., 2016).  Menstrual Management Given their primarily negative experiences of and attitude toward menstruation, menstruation management and menstrual suppression were often of interest for both cisgender women (Andrist et al., 2004; Andrist et al., 2004; Fruzzetti et al., 2008; Johnston-Robledo et al., 2003) and TGD people (Chrisler et al., 2016; Kanj et al., 2016; Lowik, 2020; Pradhan & Gomez-Lobo, 2019; Schwartz, 2022). Cisgender women took many precautions when it came to menstrual management as they often viewed menstruation as something that needed to be hidden and was not appropriate for discussion within public spaces (Burrows & Johnson, 2005; Jackson & Falmagne, 2013; Mason et al., 2013; Peranovic & Bentley, 2017). Even when cisgender women described menstruation as a natural event (Johnston-Robledo et al., 2007; Lu, 2001) or as a key aspect of womanhood (Brantelid et al., 2014; Newton & Hoggart, 2015), cisgender women maintained that menstruation was embarrassing (Johnston-Robledo et al., 2007) and should be kept in secrecy (Brantelid et al., 2014; Newton & Hoggart, 2015; Stubbs, 2008). These negative perceptions were often associated with the use of distancing language as cisgender women replaced terms such as menstruation and period with euphemisms such as it, the thing, or the time of the month (Burrows & Johnson, 2005; Jackson & Falmagne, 2013).  This need for concealment was frequently driven by shame (Brantelid et al., 2014; Newton & Hoggart, 2015) but also by the fear of others, especially cisgender men, knowing their menstrual status (Brantelid et al., 2014; Burrows & Johnson, 2005;   8  Koutroulis, 2001). In a study where female confederates accidentally dropped a tampon or a hair clip, the female confederate who dropped a tampon was rated as being liked less, evaluated as less competent, and received higher scores on measures of objectification by both cisgender men and women than the female confederate who dropped a hair clip (Roberts et al., 2002). Cisgender women reported feeling uneasy with the possibility of being shamed; therefore, they took great measures to manage and conceal their menstrual status (Burrows & Johnson, 2005; Jackson & Falmagne, 2013).  Many cisgender women explored hormonal intervention options for menstrual management and suppression. A study about cisgender women’s and providers’ attitudes toward menstrual suppression speculated that cisgender women who held negative attitudes toward menstruation were more likely to be interested in menstrual suppression (Andrist, Arias, et al., 2004). Likewise, women who viewed monthly menstruation as being messy, inconvenient, bothersome, unhealthy, and unnecessary were interested in menstrual suppression options (Johnston-Robledo et al., 2006). Multiple studies also found that a large number of cisgender women preferred to menstruate less than monthly (Andrist, Arias, et al., 2004; Fruzzetti et al., 2008; Johnston-Robledo et al., 2003, 2006; Rose et al., 2008), and nearly a third of cisgender women preferred to not menstruate at all (Andrist et al., 2004; Fruzzetti et al., 2008). The cisgender women who engaged in menstrual suppression expressed symptom management (Andrist, Hoyt, et al., 2004; Repta & Clarke, 2013) and convenience as primary reasons and also noted feeling more positive about their body when they engaged in menstrual suppression (Repta & Clarke, 2013).   9  Menstruation Management and Gender Congruence Similar to cisgender women, many TGD people described a high investment in menstrual suppression. However, the notion of gender congruence played an additional unique role in menstrual management for TGD people as most studies of menstruating TGD people have documented negative experiences of and attitudes toward menstruation as being primarily driven by a lack of gender congruence (Cavanaugh & Ladd, 2017; Chrisler et al., 2016; Eisenberg et al., 2021; Frank, 2020). Gender congruence refers to “the degree to which transgender people feel genuine, authentic, and comfortable within their external appearance/presence and accept their genuine identity rather than the socially prescribed identity” (Kozee et al., 2012, p. 181). A TGD person may independently develop and support their gender congruence through internal (e.g., self-acceptance) and/or external means (e.g., gender expression; Kozee et al., 2012). Increased levels of gender congruence may also be experienced when TGD people experience gender-confirming interpersonal processes (Nuttbrock et al., 2002, 2012) or medical interventions (Grant et al., 2011; James et al., 2016).  For example, the use of a TGD person’s chosen name and pronouns validated TGD people’s gender identity, allowing for increased gender congruence (Rodgers & O’Connor, 2017). Yet TGD people reported being “deadnamed” (i.e., being referred to by their legal/birth name rather than their chosen name) or misgendered (i.e., being referred to with non-affirming pronouns) by people in nearly half of their interpersonal interactions (Grant et al., 2011; James et al., 2016). These experiences invalidated TGD people’s gender identity (Rodgers & O’Connor, 2017), which was related to poor gender congruence (McLemore, 2015) as well as lower levels of self-esteem (McLemore, 2015)   10  and significant distress (Gridley et al., 2016). Similarly, the U.S. Trans Survey, a national longitudinal climate survey of 27,716 TGD adults, revealed that 49% of TGD people reported having received gender-affirming hormone therapy (GAHT), and 25% of TGD people reported having received some form of gender-confirming surgery (James et al., 2016). Studies that examined the relationship between gender-confirming medical care and mental health established that TGD people who sought and achieved gender-confirming medical care demonstrated an increase in positive mental health outcomes (De Vries et al., 2014; Meier et al., 2011; White Hughto & Reisner, 2016), self-esteem (Beckwith et al., 2017), quality of life (Meier et al., 2011; Newfield et al., 2006), and gender congruence (Moody et al., 2021; Owen-Smith et al., 2018).  When managing their menstruation, similar to cisgender women, TGD people echoed fears surrounding public disclosure of their menstrual status (Chrisler et al., 2016; Frank, 2020; Lane et al., 2021). Some of these concerns were similar to those of cisgender women such as leakage or being seen carrying menstrual products (Chrisler et al., 2016), but many were unique to the TGD community. TGD people voiced concerns about creating noise when unwrapping menstrual products within men’s restrooms (Chrisler et al., 2016; Frank, 2020) and generally feeling unsafe and uncomfortable in public restrooms due to their gender identity (Chrisler et al., 2016). TGD people especially noted how the social dynamics within public spaces such as public restrooms were often a source of anxiety (Lane et al., 2021) as they were at risk of discriminatory violence (Frank, 2020). In response, TGD people took additional steps to ensure the concealment of their menstrual status such as making sure they were alone (Chrisler et al., 2016; Frank, 2020), using quieter and/or longer-lasting menstrual product   11  alternatives, being discreet in using and discarding menstrual products (Chrisler et al., 2016), and opening menstrual products beforehand (Frank, 2020) so that their menstrual status was not known. These concealment practices also served as a safety mechanism to ensure that their gender identity was not exposed to others. Moreover, many transmasculine people (66%) voiced the concern that most cisgender people held negative or very negative attitudes toward transmasculine people who menstruate (Chrisler et al., 2016), a dynamic that may further augment TGD people’s attitudes toward their menstruation and level of gender congruence. Overall, TGD people shared similar concerns regarding menstrual management as cisgender women, but TGD people’s gender identity compounded their need for menstrual management as they sought gender congruence while existing within binary gendered spaces.  Menstruation Management Among TGD People In turn, while the majority of cisgender women are interested in the use of oral contraceptives to reduce menstrual symptoms (Andrist, Hoyt, et al., 2004; Repta & Clarke, 2013), the reasons for use of oral contraceptives or other hormonal intervention options for menstrual management and suppression differed greatly for TGD people. TGD people whose sex was assigned female-at-birth communicated the catastrophic feelings that came with menarche (i.e., the first occurrence of menstruation; Cleveland Clinic, 2022) as it rejected their gender identity. The experience of menarche significantly impacted the self-perception of transgender men as they questioned their gender identity and who they were (Cavanaugh & Ladd, 2017). Likewise, TGD people noted the association between menstruation and femininity. Their continued menstruation was seen as a reminder of their sex-assigned-at-birth which, in turn, impacted how they   12  viewed their gender identity (Frank, 2020). This disruption of gender congruence was related to distress about their menstrual status (Cavanaugh & Ladd, 2017; Eisenberg et al., 2021; Frank, 2020).  For that reason, 88% of TGD people were interested in menstrual suppression to manage menstrual-related distress (Schwartz et al., 2022) and 40% tried methods of menstrual suppression (Chrisler et al., 2016). Studies on medical care for menstrual management and suppression within the TGD community established that 64% and 67% of TGD people currently utilized some form of a hormonal method for menstrual management (Kanj et al., 2016) and menstrual suppression (Kanj et al., 2019), respectively. Overall, TGD people reported positive attitudes toward menstrual suppression (Chrisler et al., 2016), and the use of hormonal methods for menstrual management and suppression was associated with decreased menstrual-related distress (Eisenberg et al., 2021; Hodax et al., 2020; Lowik, 2020; Pradhan & Gomez-Lobo, 2019; Schwartz et al., 2022). By contrast, transfeminine people may desire menstruation in the interest of increased gender congruence. In a study on reproductive lives, Lowik (2020) discussed how one transfeminine individual wished to menstruate to achieve womanhood. The study also commented on the concept of a “bloodless period,” in which transfeminine people reported menstrual-like symptoms upon receiving gender-affirming hormone therapy. Other than this brief mention, there is no published research focused on menstruation within the transfeminine population. It is critical that this emerging area of research includes the voices of TGD people whose sex was assigned male-at-birth and   13  seeks to further understand the needs of transfeminine people, especially as it relates to their lived experiences of a “bloodless period” (Lowik, 2020). Current Study The current study engaged transfeminine voices in a discussion of menstruation by exploring the phenomenon of the “bloodless period.” Specifically, the goal of this study was to understand transfeminine people’s unique experiences of having a “bloodless period.” This study also aimed to review 1) the ways in which transfeminine people conceptualized and understood the presence of their “bloodless period” and the role it played within their day-to-day lives, 2) the ways in which interpersonal relationships and contextual factors influenced transfeminine people’s perception of their menstrual-like symptoms, and 3) the role of the “bloodless period” as it related to transfeminine people’s gender identity and gender congruence. Grounded in the current literature on menstruation within the TGD community and critical (Horkheimer, 1975) and queer (Gamson, 2000; Wozolek, 2019) theories, an IPA (Smith & Osborn, 2008) approach was used and the following research questions guided the study: 1) How, if at all, do transfeminine people conceptualize and experience their “bloodless periods?”, and 2) How, if at all, does the presence of menstrual-like symptoms relate to transfeminine people’s sense of gender congruence?  Method  There is a lack of research examining the experiences of the “bloodless period” among transfeminine people. It is important to begin this line of research by starting to focus on describing and understanding how menstrual-like symptoms are experienced and its associated meaning, particularly related to gender, among the transfeminine   14  population. Therefore, Smith and Osborn’s (2008) IPA approach was utilized to examine the everyday lived experiences of transfeminine people experiencing a “bloodless period.” Such an approach suspends preconceived assumptions about the transfeminine population and about “bloodless periods” in the interest of interpreting the meaning and patterns of commonalities within this phenomenon while reducing the influence of previous biases (Hycner, 1985). A queer theoretical paradigm was implemented to explore the lives, experiences, and identities of the transfeminine people. Queer theory considers the role of societal heteronormative and binary gendered expectations as it relates to gender and sexual identities and seeks to understand its impact on lesbian, bisexual, gay and TGD people’s and group’s day-to-day lived experiences (Gamson, 2000; Wozolek, 2019). By applying a queer lens, I was able to take into consideration the lived experiences of transfeminine people as queer people within a heteronormative and binary society. In addition to employing a queer lens, a critical perspective (Horkheimer, 1975) was applied in order to also acknowledge and critique the larger sociopolitical context and systems of power as they related to and impacted transfeminine people and how they understood and navigated their world. This approach allowed me to understand and challenge these structures and promote positive social change within the transfeminine community. Together, I applied a critical queer IPA approach to the current study. This approach allowed me to best delineate the lived experiences of transfeminine people and detail the meanings and commonalities behind this population’s experience of the “bloodless period” while considering their queer identities and the role of social norms and oppressive experiences.   15  Researcher-as-Instrument Statement I am a third-year Counseling Psychology doctoral student within a social justice-oriented graduate program, and my primary area of research is on issues pertaining to the health and wellness of TGD people. I have received extensive education, clinical training, and research experience in topics related to gender and sexuality, specifically within the lesbian, gay, and bisexual community and the TGD population throughout my undergraduate and graduate career. I have completed six semesters and one semester of research methods and data analysis courses in quantitative methods and qualitative methods, respectively. I also have six years of research experience. As I conducted this study, I continued to receive mentorship from a research committee and a primary research advisor with experience in qualitative research and methodologies as well as gender and sexuality scholarship.  I identify as non-binary and am a previously menstruating person. I have achieved life-long menstrual suppression through medical intervention as a form of menstrual management and to promote my own gender congruence; therefore, I have a personal and professional investment in the current topic of research. However, these identities introduce potential biases including negative experiences of and attitudes toward menstruation, which are congruent with menstruation literature, and personal lived experiences of menstrual management as a non-binary person. I engaged in phenomenological reduction by seeking consultation with my research committee to raise awareness around my biases and bracketed my assumptions and biases as much as possible to “understand what it is like, from the point of view of the participants” (Smith & Osborn, 2007, p. 53). I also engaged in journaling during and immediately after each   16  interview to reflect on immediate reactions and interpretations of the participants’ responses. Additionally, participants had the opportunity to review the codebook and provide feedback on their accuracy and whether it fully captured their lived experiences. Particular attention was paid to suspending my expectations about the role of gender identity and experiences of menstruation through this process of bracketing (Gamson, 2000; Hycner, 1985; Tufford & Newman, 2010). Rather, I was intentional about inquiring about how participants conceptualized their gender identity and how social messages have informed their performance of gender. I adopted their language and worldviews as best as I could to better understand the participants’ perceived gender and social influences. This process allowed me to withhold my own biases about gender and menstruation, appreciate the participants’ viewpoint, and apply a critical lens from their standpoint. Participants This study was approved by the Institutional Review Board (IRB), and the recruitment of participants took place online through social media platforms and listservs of well-established LGBTQIA+ community resource centers (e.g., PFLAG, CenterLink, university resource centers) across the United States. A flyer containing information about the study (See Appendix C) was provided to the community resource centers to be posted on their social media pages and sent to their listservs. The flyer included a link and QR code to a screener survey hosted via Qualtrics, an online survey platform. Those interested in the study were asked to review the consent form (See Appendix A), indicate consent for participation, and complete the screener questions (see Appendix E) from a personal computer or mobile device. To be eligible for the study, participants had to (1)   17  be assigned male-at-birth, (2) identify as transfeminine, (3) experience recurring menstrual-like symptoms, (4) be the age of majority within their place of residence (i.e., a legal adult), (5) live in the United States, and (6) speak English.  Participants who met the criteria for the study were redirected to the demographic questionnaire hosted via Qualtrics. Participants completed the Menstrual Distress Questionnaire (MDQ; Moos,1986; See Appendix F) and a short demographic questionnaire (see Appendix G) that lasted roughly 10 to 15 minutes and included demographic measures such as age, race and ethnicity, sex-at-birth, gender identity, sexual orientation, education level, student status, relationship status, employment status, socioeconomic status, religious or spiritual affiliation, gender-affirming hormone therapy status, and whether or not they experience a “bloodless period.” At the end of the demographic questionnaire, participants who were interested in participating in a semi-structured interview about their experiences of a “bloodless period” were prompted to provide their contact information (i.e., email, phone number). I contacted eligible participants to schedule a time for the interview. The study had originally aimed to recruit 10 to 12 (Guest et al., 2006; Moser & Korstjen, 2018; Sim et al., 2018) racially and ethnically diverse transfeminine adults to participate in a demographic questionnaire and an approximately one-hour semi-structured interview. A stratified sampling method was employed with a goal to have half of the sample represent transfeminine people of color in order to attend to the issues of trans-misogyny experienced by transfeminine people (Arayasirikul & Wilson, 2019), which is exacerbated for transfeminine people of color (Krell, 2017). However, due to the recruitment challenges that arose, as discussed below, I was unable to meet this goal. A   18  total of ten transfeminine adults in the United States completed a one-hour semi-structured interview. The mean age was 30.28 (SD = 10.68) and ranged from 19 to 56. All ten of the participants identified as White and reported current and history of hormonal replacement therapy (GAHT). Pseudonyms and salient identities, as shared by participants on demographic questionnaire, of the participants are reported in Table 1. Table 1. Participant Demographics Pseudonyms Salient Identities Julia Richards Transgender woman, lesbian, queer, mental health disorder, late teens Anna Q Genderfluid, lesbian, neurological developmental disability, late 20s Valkyrie Transgender woman, lesbian, asexual, queer, mental health disorder, mid 30s Violet Transgender woman, lesbian, asexual, queer, mental health disorder, early 30s Jelli Demigirl, pansexual, able-bodied, early 30s Melaney Transgender woman, pansexual, mental health disorder, early 40s Lucy Carter Transgender woman, lesbian, able-bodied early 20s Michelle Gender queer, pansexual, queer, chronic condition, mid 50s Io Transgender woman, pansexual, queer, chronic condition, mid 20s Alice Transgender woman, demisexual, neurological developmental disability, mid 20s  In the interest of obtaining descriptive data about how participants experienced their menstrual-like symptoms, they responded to the MDQ (Moos, 1986), a 46-item self-  19  report questionnaire measuring distress related to eight subgroups (i.e., pain, concentration, behavioral changes, autonomic reactions, water retention, negative affect, arousal, control) of menstrual symptoms. Participants rated the severity of their menstrual symptoms on a 5-point Likert scale (1 = No experience of symptom; 2 = Present, Mild; 3 = Present, Moderate; 4 = Present, Strong; 5 = Present, Severe). Overall, participants reported mild to moderate distress (M = 2.49, SD = 0.44) related to menstrual symptoms. See Table 2 for means and standard deviations for each of the eight subgroups of menstrual symptoms. Table 2. Descriptive statistics of menstrual distress Factor M (N = 10) Std Pain 3.09 0.59 Concentration 2.10  0.72 Behavioral changes 2.96 0.83 Autonomic reactions 2.03 0.46 Water retention 2.38  0.49 Negative affect 3.29 0.90 Arousal 2.06  0.75 Control 1.77  0.56 Overall distress 2.49  0.44  Given that the recruitment of participants primarily occurred online, the study was highly susceptible to fraudulent data due to bots (Pozzar et al., 2020). A bot is a “software program that performs automated, repetitive, pre-defined tasks” (Kaspersky,   20  n.d., para.1) and can quickly find online studies that include monetary incentives (Molinaro, 2022). Bots negatively impact data integrity and can be especially problematic within research on populations with marginalized identities (Griffin et al., 2022). I protected the current study from fraud as much as possible by implementing multiple preventative measures as recommended by the IRB (Hildebrandt, 2020). For example, I made use of Qualtrics’s Captcha (Completely Automated Public Turing Test; Qualtrics, 2022a), bot detection, security scan, and metadata analysis (Qualtrics, 2022b) features to deter potential bots. I also implemented attention checks (e.g., requesting that participants select a specific response), skip logic (i.e., skipping question(s) that do not apply to ineligible participants), and prevented multiple submissions (Simone, 2019). Finally, during the data cleaning process, I followed recommendations from Pozzar and colleagues (2020) to assess the survey for evidence of inattention via unusual time stamps and competition time or repetitive response style (e.g., same response for every question), duplicate or unusual responses to items, inconsistent responding, and clear evidence of bot behavior (e.g., responses to honeypots, which are questions hidden in the website’s coding that only bots can see).  Despite my best efforts to prevent bots and fraudulent data, I experienced a high number of bots and fraudulent behaviors. The online Qualtrics survey received 514 responses. However, over 95% of the responses were incomplete or identified to have been completed by bots or were fraudulent responses. Responses were flagged as fraudulent based on unrealistically short response times, non-US GEO-IP addresses, repeated back-to-back entries in an attempt to bypass the screener questions, inaccurate or false contact information, inaccurate/unrealistic responses to open-ended questions,   21  and duplicate IP addresses, email addresses, and phone numbers (Teitcher et al., 2015). Interviews were scheduled with 16 participants from the remaining pool of prospective participants (n = 33) after following the aforementioned recommendations for data cleaning. However, after engaging the participants in an interview, I suspected that six of the participants were falsifying their responses. The suspected fraudulent participants had their cameras turned off during the duration of the interview and had low-quality audio, a feature that was commonly noted among fraudulent interviews (Sefcik et al., 2023). The suspected fraudulent participants also hesitated, had difficulty answering the interview questions (Roehl, & Harland, 2022), frequently used language that was used in the consent form, and were often unable to provide additional detail when asked probing questions (Roehl, & Harland, 2022). There were also discrepancies between the information provided on the demographic survey versus the interview (e.g., hormonal treatments) and inconsistencies throughout the interviews. Furthermore, the suspected fraudulent participants' responses were similar to each other, while also differing from the responses of the verified participants. In response, I followed the recommendations of other scholars, based on anecdotal experiences, on how to respond to fraudulent participants (Sefcik et al., 2023; Teitcher et al. 2015) and excluded their interview data from the analysis.  Sources of Data Participation in the study occurred through online surveys hosted via Qualtrics and a semi-structured interview via a Zoom videoconferencing call. I conducted the interviews from a quiet and private space, and I also encouraged the participant to attend the interview within a quiet and private space. The primary data source was interviews   22  which ranged from 34 minutes to 80 minutes, with an average duration of 52 minutes. Based on the literature related to menstruation within the TGD community and consultation with committee members, a semi-structured interview (see Appendix H) guided discussions with participants. At the start of the interview, I introduced myself, the purpose of the study, research questions, and asked for consent to record the interview before conducting the interview. During and immediately after the interviews, I took notes on common themes that emerged within and between each interview to guide future coding of the interview transcripts. I also reflected and journaled on initial thoughts and emotional reactions to the participant’s responses and overall interview to promote bracketing of biases. Those who completed both the demographic survey and the semi-structured interview were compensated $50.00 in the form of an electronic gift card. Data Analysis Descriptive statistics for the MDQ and demographics were computed using SPSS v. 26. The interviews were transcribed using Rev, an online automated artificial intelligence-based transcription service, and checked for accuracy. The transcriptions were uploaded to the latest version of NVivo, a qualitative data analysis software, for coding and analysis while following Smith & Osborn’s (2007) interpretive phenomenological analysis guidelines using an empathic and questioning hermeneutics approach aimed at the identification of themes to explain the lived experiences of participants. I conducted multiple readings of the transcripts then began an initial coding of experiential statements which aimed to summarize and paraphrase the experiences shared by participants while adopting their language. The experiential statements were then categorized into emergent themes. Emergent themes consisted of concise phrases   23  informed by the summarized and paraphrased phrases from the initial coding of experiential statements. Additionally, the emergent themes served as the initial step in building connections between stories shared and to capture the essential quality of the experience shared by participants. This process was completed for each interview to minimize the influence of previous codes and emergent themes on successive transcriptions.  At this stage of the study, the participants were invited to review for accuracy and provide feedback on the experimental codes and emergent themes identified for their interview transcript. Six of the ten participants communicated that the experimental codes and emergent themes accurately represented their experience, one participant provided minor written feedback providing revised language to better capture their experiences (which was adopted by the author), and three participants did not respond to the invitation. The feedback was implemented accordingly. I edited the codebook the suggested revised language, and the individually coded transcription files were then imported into one NVivo project file so that all experiential codes and emergent themes from each interview could be viewed together for continued coding. Next, any remaining initial experiential codes that were not included in the experiential themes for their transcript were categorized into the appropriate accumulated emergent themes across all coded interviews.  The emergent themes were then categorized into clusters of relevant meaning. Clusters were formed through the process of grouping similar and related emergent themes together with the intention of connecting the shared experiences between the participants. After the clusters were created, I developed a codebook that included each   24  cluster, the frequency of each cluster, and the number of participants for whom the cluster was coded. After the initial codebook was formed, I reviewed the codebook and determined whether there were any redundancies and low frequency clusters and characterized the clusters as they related to the research questions. I discussed my rationale for removing or retaining clusters and characterization of clusters with my research advisor. After eliminating redundancies, the clusters were then categorized into themes by me, my primary research advisor, and third-party colleague and compared for intercoder reliability. The production of themes was the final step in the coding process. The themes are composed of clusters that share related ideas and reflect a larger shared topic of concern. I reviewed the three sets of themes and noted the similarities and differences between the theme titles and categorization of clusters. I maintained the themes and clusters that were consistent across for all three coders, and recategorized discrepant clusters based on commonalities between the three coders. Lastly, I titled the themes to best reflect common language used by all three coders and finalized the codebook. Results Data analysis yielded five themes and 15 clusters (see Table 3). The five categories were (1) Emotionally and physically adjusting to GAHT, (2) Learning to engage in menstrual management in daily life, (3) Menstrual symptoms support positive gender congruence, (4) Need for increased transfeminine inclusivity, and (5) Unlearning binary and sex-negative social messages. In contrast to the introduction, recruitment material, and interview protocol, the phrases “menstrual symptoms,” “menstrual cycle,” and similar were adopted and used in lieu of the phrases “menstrual-like symptoms” and   25  “menstrual-like cycle,” respectively, to best reflect the participants’ language and to prevent further invalidation of their experiences.  Table 3. Themes and Clusters. Themes n Codes Clusters Emotionally and physically adjusting to GAHT 10 163 Process of recognizing symptoms post GAHT Experience of physical and emotional menstrual symptoms Learning to engage in menstrual management in daily life 10 161 Engaging in menstrual management and coping skills Factors influencing ability to track menstrual cycle and symptoms Negative impact of menstrual symptoms on day-to-day tasks  Menstrual symptoms support positive gender congruence 10 240 Conceptualization of gender and intersecting identities Desire for traditional menstrual experience and pregnancy capabilities Positive affect and attitude toward menstruation Womanhood achieved through menstruation  Need for increased transfeminine inclusivity   10  230  Desire for improved access to care  Experiences of invalidation Experiences of support and resources through connections  Unlearning binary and sex-negative social messages  10 148 Experience of conflict between personal beliefs and social messages   26  Shift from traditional to more fluid definition of menstruation Stigmatizing and binary social messages regarding menstruation  Emotionally and Physically Adjusting to GAHT All the participants (n = 10) were able to recall roughly when their menstrual symptoms first developed. The participants each noted that the physical and emotional menstrual symptoms started after receiving GAHT treatments. This theme was composed of two clusters: (1) Process of recognizing symptoms post GAHT (n = 4) and (2) Experience of physical and emotional menstrual symptoms (n = 10).  Process of Recognizing Symptoms Post GAHT The participants (n = 4) shared their processes of coming to recognize and acknowledge their menstrual cycle. For example, Io noted how her partner had drawn her attention to her reoccurring symptoms and suggested that “maybe this is your period.” Violet suspected that she was experiencing a cycle but “[she] didn’t feel like [she] had the right to call it [menstruation] until someone else basically ‘gave [her] permission’ to call it that.” Alice described both an independent process of gradual recognition and an immediate acceptance of her menstrual cycle: I know it took three months for me to realize that it was probably a period. That was when I was first putting the dots together and was like, “Wait, I think this is it.” Then after the fourth time, I was like, “Okay, yeah.” And I was—there was a lot of questioning and doubt in my mind, but I realized that a lot of that is—if I   27  was cis[gender], I wouldn't be questioning it so hard, you know? And so, I just decided not to. Participants did not immediately notice the presence of a cycle. The process was gradual, and participants became aware of their symptoms a few months to about a year after the initial onset. This process was either independent or aided by partners and friends who also noticed and pointed out the participant’s cycle of symptoms.  Experience of Physical and Emotional Menstrual Symptoms  After the participants became aware of their menstrual symptoms, all the participants (n = 10) noted experiences of both physical and emotional symptoms. For example, Michelle reported monthly symptoms such as “cramping,” “bloating,” “cravings,” and “tiredness” as some of the physical symptoms she experiences. Jelli noted “a change in the type of orgasm that [she] would experience.” As for emotional symptoms, participants noted experiences of “sadness,” “depression,” “irritability,” “impulsivity,” and “heightened anxiety.” All the participants also indicated the presence of “mood swings” or “emotional fluctuations.” Anna Q communicated an increase in sensitivity after receiving GAHT:  When I started taking hormones, I would start crying a lot more, especially at things that I don't think are sad or things that I would normally want to cry about. That was kind of where I started noticing [my cycle], was that I would just start crying at things that I had no reason to cry about. Then over time, especially increasing my dosage, started getting more emotional and noticing those emotions.   28  Overall, the emotional and physical menstrual symptoms began after the participants received GAHT. Many of the symptoms shared (e.g., cramping, bloating, cravings, fluctuations in mood) were similar to menstrual symptoms reported by cisgender women. There were no symptoms shared that were not historically associated with menstruation, so it is unknown whether participants experienced additional symptoms that may not be typically understand as menstrual symptoms.  Learning to Engage in Menstrual Management in Daily Life As the participants (n = 10) continued to experience a regular cycle, they voiced the importance of increasing awareness around their cycle and practicing positive coping skills to manage their menstrual symptoms as a part of their daily lives. Clusters developed from this theme included (1) Factors facilitating or limiting ability to track menstrual cycle and symptoms (n = 7), (2) Negative impact of menstrual symptoms on day-to-day tasks (n = 7), and (3) Engaging in menstrual management and coping (n = 6).  Factors Influencing Ability to Track Menstrual Cycle and Symptoms Most participants (n = 7) communicated different factors that influenced their ability to track their menstrual cycle and symptoms. Anna Q, Io, and Valkyrie explained how the lack of a physical indicator of menstruation a barrier was to recognize their cycle. Valkyrie mentioned that “it [could] be hard to identify also because there's no bleeding.” Despite this added barrier, Melaney and Violet were able to track their menstrual cycle and symptoms using a menstrual tracking application on their phones. Melaney asserted that “it's generally the same. It's generally spot on.” Moreover, Alice and Michelle also shared their unique experience of their cycles synching with the moon   29  phrases. Alice explained how she was able to time her menstrual cycle similar to cisgender women through the use of oral contraceptives:  When I started taking [progesterone], that's when it started happening. And specifically, what I do at the advice of my endocrinologist is, for a week, I just go off progesterone. That’s the period week. That regulates my cycle. Then, I synced it up with the cycles of the full moon because that's cool. Whenever there's a full moon, that is when I stop taking it. That means that I have some amount of control of when it happens. The absence of bleeding was a primary barrier for participants in building awareness of their menstrual cycles. Additional factors such as “chronic conditions”, “stress”, and “menstrual synching” (i.e., synchronization of one’s menstrual cycle with another menstruating person) also made it difficult for participants to follow their cycles due to changes in the timing of their symptoms and/or uncertainty about whether their symptoms were explained by a different reason. Even so, the participant’s menstrual cycles were typically regulated. This allowed participants to track and predict their menstrual cycles with a high level of accuracy.  Negative Impact of Menstrual Symptoms on Day-to-Day Tasks As participants took note of their menstrual symptoms, most participants (n = 7) communicated some level of negative impact on their ability to engage in daily activities. Jelli described it as though “life goes on challenge mode for a little bit.” Valkyrie echoed this sentiment noting how, for her, “it hurts. It's draining. It's like emotionally taxing.” Moreover, Lucy Carter demonstrated how she altered her plans due to her menstrual symptoms:    30  It's definitely caused me to slow down and has hindered some of my day-to-day tasks before being a social person wanting to go out and do things. I've definitely canceled because of [the symptoms] or need to spend my day sitting more at my desk at work, for example, as opposed to being up and about and moving things around or things like that. Although participants welcomed their menstrual cycle, the participants also recognized the discomfort that came with the symptoms. Their experiences of menstrual symptoms dampened their ability to socialize, fulfill employment responsibilities, and complete domestic tasks. Nevertheless, the participants communicated a sense of tolerability and were still able to tend to their tasks as needed. Engaging in Menstrual Management and Coping Skills  In response to the negative impact of their menstrual symptoms, many participants (n = 6) learned positive coping skills and established what worked best to relieve their symptoms. Violet communicated that “[she] often gave [her]self permission to be gentler on [her]self instead of trying to simply push through.” Michelle highlighted a variety of alternative and natural remedies she engaged in to cope with her symptoms: I do singing bowls. So around that time of the month, I like to do my singing bowls. I like to do music stuff. Chinese medicine. The liver is responsible for the easy and smooth movement of emotions, so I like to play an instrument near my liver to kind of allow that. I also do Qigong and Tai Chi and meditation around the time of the month or yoga to kind of help move that emotions because really when you get stuck emotions, you get stuck Chi and stuck blood. That's gonna really start to affect the way you work your life.   31  Participants primarily opted for natural remedies to address their menstrual discomforts rather than medications and other medical interventions. Physical relief was often achieved through the use of warm compresses, massages, and calming drinks and foods. Additionally, participants provided space to engage in mindfulness and self-compassion. This allowed participants to reflect on their emotions and bodily sensations without judgement. Regardless of the level of discomfort, participants maintained that they would prefer to keep their symptoms and not turn to menstrual suppression options.  Menstrual Symptoms Support Positive Gender Congruence All the participants (n = 10) maintained that their experience of menstrual symptoms provided positive gender congruence and supported their identity as women. This theme was built upon four clusters: (1) Conceptualization of gender and intersecting identities (n = 6), (2) Positive affect and attitude toward menstruation (n = 7), (2) Womanhood achieved through menstruation (n = 10), and (4) Desire for traditional menstrual experience and pregnancy capabilities (n = 5).  Conceptualization of Gender and Intersecting Identities In understanding their identity as women, many participants (n = 6) reflected on their conceptualization of gender and how other aspects of their identity informed their gender. For example, sexual identity “factors into [her] gender identity” for Valkyrie and “kind of also plays a role in like how [she] present[s] and like dress[es]” for Anna Q. Additionally, Jelli described what it meant to be a demi girl:  As a demi girl, I am—I did think I was bigender for a while because being a demi girl is—it's a blend of stereotypes. And in that way, it feels somewhat like it's not non-binary. It feels contrasted to non-binary because, whereas non-binary   32  inherently is more of like, “Fight the power. I'm not gonna fit in these boxes.” Demi girl is like, “No, no, no. Let me just pour a little bit out of these boxes onto myself. I like having these traits, these things.” Gender was defined in both a fluid and binary manner. Participants discussed their experiences of gender as being flexible and non-restrictive. At the same time, participants highlighted their efforts to present as women. Furthermore, participants considered other aspects of their identities such as sexuality and social and cultural messages that informed their gender.  Positive Affect and Attitude Toward Menstruation Most participants (n = 7) described their menstrual symptoms as a positive experience for them. Julia Richards shared that “[she] was excited for [her]self” upon realizing she had a cycle. Lucy Carter also indicated that “[she was] happy with where [she was] at,” and Violet described her menstrual symptoms as “a triumphant feeling.” Moreover, Michelle demonstrated a strong desire for her menstrual cycle:  I actually feel it to be very desirable. If I had known that this is part of my transition, I would've jumped into it sooner … It's empowering. I'm very empowered by it. I just think that it's empowering for me. My bloodless period's very empowering for me.”  Overall, participants expressed generally positive affect and attitudes toward their menstrual symptoms. The menstrual symptoms were typically welcomed and viewed as a desirable experience by the participants as it affirmed their identity as women; therefore, the transfeminine people in this study wished for menstrual symptoms. Womanhood Achieved Through Menstruation    33  There was a sense of womanhood that was achieved through their experiences of menstrual symptoms for all the participants (n = 10). Lucy Carter disclosed that she is "genuinely in line with the gender that [she] identif[ied] with” and that “it makes [her] feel more like a cis[gender] woman.” Julia Richards also shared that “menstruation is a thing that gives [her] euphoria because it feels like something that aligns with [her] identity as a woman”. Furthermore, Melaney reflected on whether there were benefits to her menstrual cycle beyond confirming her womanhood:  From my own perspective, it is an extra validation to me that my body is responding in a way that it would have I been born physiologically female…It's an extra validation that my lived experience makes sense and is right for me.  It was clear that the participant’s experiences of menstrual symptoms confirmed their womanhood and provided a strong sense of gender congruence. The presence of menstrual symptoms signaled to the participants that their body was responding to the GAHT and undergoing a feminine transformation. Moreover, all the participants confirmed that they felt “cramps” where their uterus and/or ovaries would be if they had them, which further supported their womanhood.  Desire for Traditional Menstrual Experience and Pregnancy Capabilities  Although all the participants expressed positive attitudes toward their menstruation and experienced gender congruence from their menstrual symptoms, half the participants (n = 5) wished for the capacity to bleed and/or pregnancy. Io “wish[ed] [she] could bleed…[she] wish[ed] [she] had that capability.” Jelli and Melaney both expressed feeling “envious” of those who could become pregnant. Moreover, Michelle revealed that her desire for the capacity to become pregnant stemmed from childhood:    34  Growing up, my mother and my sister didn't talk about [menstruation and reproductive health] that much. I was raised to read a book called Our Body, Ourselves, so I understood women a lot. Like I kept on looking at the pictures going, “When does this happen to me? When does that happen to me?” And I didn't realize it until later that I was like, “Oh, it won't.” The desire for bleeding and capacity for pregnancy was closely linked to womanhood. Participants acknowledged that menstrual bleeding would be an “inconvenient,” “uncomfortable,” and “unpleasant" experience, but they still desired it and wanted to experience all aspects of menstruation. Likewise, participants yearned for possible technological advances that would allow them to become pregnant and give birth as it was highly connected to womanhood.  Need for Increased Transfeminine Inclusivity  All the participants (n = 10) communicated a need for the inclusion of transfeminine voices and experiences in conversations regarding menstruation in both formal (e.g., research, medicine) and informal (e.g., social spaces) settings. This need for increased inclusivity informed the creation of three clusters: (1) Desire for improved access to care (n= 9), (2) Experiences of invalidation (n = 6), and (3) Experience of support and resource through connections (n = 10). Desire for Improved Access to Care  Nearly all (n = 9) of the participants communicated difficulty finding helpful information and resources related to menstruation for transfeminine people. Julia Richards voiced that her “biggest challenge is just like uncertainty because of the fact that there's not a lot of resources or information.” Likewise, Io commented on an overall lack   35  of available information, stating that “there’s like no academic research. The only information there is mostly like trans femme people mentioning to other trans femmes about their experience or whatever. And so, it feels like such a—not understood.” Overall, participants primarily sought information about their menstrual symptoms online. They engaged in independent research in hopes of learning more about what they were experiencing and whether it was a regular occurrence. However, the main source of information consisted of anecdotes of other transfeminine people shared on online forums and groups (e.g., Reddit, Discord, Facebook). In response, the participants expressed a desire for improved access to resources and care from medical professionals and researchers. Experiences of Invalidation Over half (n = 6) of the participants’ menstrual experiences were invalidated by other people. Julia Richards shared that “[her] therapist [has] said the symptoms are probably not what [she] think[s] they are.” Io also received comments from “some people who were like, ‘That's like not real,’ or ‘It's not the same.’” To protect herself, Violet disengaged in potentially invalidating situations:  I noticed that if I claimed certain aspects of womanhood as it were, people would push back against it or claimed that I was overstepping my bounds, that I was “a misogynist.” And so, I would step back from making claims to certain aspects of womanhood for fear of being mistreated or invalidated by the people around me. Unfortunately, it was not uncommon for the participants to experience invalidating comments regarding their menstrual experiences. The comments came from a variety of sources including partners, family members, friends, professionals, and strangers. Some   36  participants shrugged the comments off, and other participants chose to conceal their experiences to prevent invalidation. Experiences of Support and Resources through Connections  In contrast to their experiences of invalidation, all the participants (n = 10) reported access to positive support systems. Violet noted that “it was mostly from AFAB folks that [she] learned more about [menstruation].” Additionally, Julia Richards shared how she was supported by her partner:  Usually, I can talk to my girlfriend who, again, I know I say girlfriend, but he is gender queer. I can speak with him, and he'll comfort me or loan me a heating pad that he no longer really gets so much use out of. The experience can be generally pleasant. I think if I was experiencing those symptoms alone and without some of the resources that I have, they would probably be a little more troubling. But as it stands, I think it's nice. All the participants identified multiple avenues in which they received support including friends, partners, and connections to transgender communities via online and local groups. They received both emotional (e.g., validating comments, space to talk) and physical supports (e.g., massages, bringing supplies) from others throughout the development and on-going management of their menstrual symptoms. Moreover, people with uteruses were an important source of information as participants did not receive education on menstruation in formal settings.  Unlearning Binary and Sex-Negative Social Messages All the participants (n = 10) shared experiences of reflecting on the binary and sex-negative social messages they received regarding gender and menstruation   37  throughout their youth and adulthood. The participants shared their journey of unlearning these messages and reconceptualizing gender and menstruation from a more inclusive lens. Within this theme, three clusters were established: (1) Stigmatizing and binary social messages regarding menstruation in cisgender spaces (n = 8), (2) Experience of conflict between personal beliefs and social messages (n = 6), and (3) Shift from traditional to more fluid definition of menstruation (n = 10).  Stigmatizing and Binary Social Messages Regarding Menstruation  Most participants (n = 8) recalled having received stigmatizing and binary social messages regarding menstruation in primarily cisgender spaces (e.g., friends, family, strangers). Participants noted how cisgender people descried menstruation as “annoying,” “messy,” “an unwelcome surprise,” “taboo,” “frustrating,” “shameful,” “or “icky.” Similarly, Violet disclosed that “[she] did not receive any positive messages” about menstruation and was “taught that a period was something shameful, that should be hidden and not talked about or acknowledged by anyone.” It was not until adulthood that Violet “unlearned a lot of that stuff.” Furthermore, Anna Q revealed feelings of exclusion due to binary messaging: Especially with a lot of like the abortion bans, there's a lot of messaging around like periods and like giving birth that were very centered on women do this, especially like cis women do this. That was definitely part of the messaging. That was more of a negative messaging like maybe I'm not part of this or like feel excluded from this in some ways. The participants received primarily negative messages related to menstruation. Participants noted a lack and active suppression of discussions about menstruation, and,   38  when conversations occurred, they observed that menstruation was usually stigmatized. These attitudes were often maintained by cisgender people. Furthermore, it was difficult for the participants to join conversations about menstruation because of gatekeeping in cisgender spaces.  Shift from Traditional to More Fluid Definition of Menstruation  In unlearning binary and sex-negative messages, all the participants’ (n = 10) understanding of menstruation evolved. Anna Q shared that “for a long time [she] associated it mostly with bleeding as a form of menstruation.” And, in response to these messages, Julia Richards shared her current gender-inclusive conceptualization of menstruation in contrast to her previous traditional understanding of menstruation:  I really do think that menstruation as a concept is divorced from the identities of the people experiencing it. It's a bodily thing related to your anatomy, not something related to your social identity. Therefore, I don't really think that it's inherently something that's feminine. I think it's more correlation than causation. It happens to be that a large majority of people are cisgender, and therefore a large majority of cisgender women are experiencing menstruation. Therefore, there becomes this correlation. But I really don't see it as something that's inherently feminine. It's more that it's just something that is aligned with femininity due to circumstance. Moreover, Alice voiced the importance of also engaging in dialogue with others to continue to destigmatize menstruation and encourage gender-inclusive perspectives. She noted her role in facilitating menstrual conversations with cisgender men to promote that shift in understanding:   39   One of my favorite things is talking to people who don’t get [periods], cis[gender] guys like my brother and my dad, and helping them better understand what it’s actually like and shift their perspective on [menstruation] … Cis[gender] men don’t really talk about [menstruation] except from an outsider perspective of maybe they have an understanding that [menstruation] is annoying or that people can be irritable. Maybe they’ll complain about that, but they don’t really talk with each other. There’s a big stigma against that. That’s honestly one of my favorite things about being trans in general is being a bridge that can help connect people and help people better understand gender … It’s really nice to just break down that stigma.  The participant’s definitions of menstruation shifted away from a traditional understanding of menstruation as being primarily physical and requiring bleeding. Rather, their definitions became more holistic and took into consideration physiological, hormonal, emotional, and psychological components of menstruation. They also challenged the notion that menstruation was something “shameful,” “to be hidden,” gendered and binary. Rather, the participants shifted to a gender-inclusive and sex-positive understanding of menstruation.   Experience of Conflict Between Personal Beliefs and Social Messages  A challenge arose for the participants as they continued to redefine menstruation. Many participants (n = 6) encountered conflict between their desire to push back against binary and sex-negative messages while also maintaining their gender identity and navigating a gendered society as a gendered person. Anna Q stated that “[she] sees that   40  connection there” but will also “try not to see a connection” in reference to menstruation and womanhood. Similarly, Valkyrie revealed her difficulty in striking a balance: I think I am doing my best to navigate a place where I can push back against a lot of those beliefs while still being seen as a woman. It's a tough line to walk sometimes, but I am typically outspoken in the spaces that I'm in pushing back against misogyny and trans misogyny and a lot of the bigotry that comes with a lot of these kind of societal norms. But on the other hand, I'm also doing my best to be as like, stealth and passing as possible, which is a double-edged sword. By doing that, that means that, in a number of spaces, I'm not out about who I am. I am conforming to societal expectations, and I am treated in the ways that like women are treated in those spaces. This dynamic often produced a feeling of cognitive dissonance for the participants. Participants strived to challenge binary gendered messages. However, they also recognized their desire to be socially acknowledged as women, which occasionally demanded conforming to conventionally feminine ideals. Participants recognized the conflict between these perspectives; therefore, they emphasized the importance of individual goals for gender congruence.  Discussion Using a critical queer IPA approach, this study explored how transfeminine people receiving GAHT conceptualized their “bloodless periods” and how their menstrual symptoms related to their sense of gender congruence. Participants experienced regular physical and emotional menstrual symptoms on a monthly cycle after receiving GAHT treatment. In the absence of bleeding, participants used other methods   41  (e.g., journals, mobile applications) to track their cycle and practiced positive coping skills to manage their symptoms. Participants communicated positive attitudes toward menstruation and described their menstrual symptoms as a favorable experience. With that said, all the participants emphasized that their menstrual cycles supported their gender congruence and confirmed their identity as women. Concurrently, participants acknowledged the stigmatization of menstruation, particularly in cisgender spaces with friends, family, and strangers. Participants received invalidating messages that reinforced the gender binary, asserting that menstruation was reserved for cisgender women and required bleeding. Regardless, they shifted from a traditional understanding of menstruation (i.e., bleeding and shedding of the uterus) to a more gender-inclusive and holistic understanding of menstruation. Yet, the participants also conveyed continued conflict between their viewpoints and the binary and sex-negative social messages they have received. The participants reaffirmed the importance of sustaining a gender inclusive view of menstruation while also acknowledging that gender is self-defined by and informed by intersecting identities and cultural beliefs. At the same time, the participants were keenly aware of their identities as transgender women as they navigated their lives as gendered people in a gendered society.  Integration with Previous Literature  Access to Information Reflective of studies on cisgender women (Grandi et al., 2012; Iacovides et al., 2014; Schoep et al., 2019; Yamamoto et al., 2009), menstrual pains were commonly reported by the transfeminine participants along with other emotional (e.g., impulsivity, anxiety, sadness) and physical (e.g., bloating, fatigue, nausea) menstrual symptoms after   42  receiving GAHT treatments. The experiences of menstrual symptoms also negatively impacted the transfeminine participants’ ability to engage in daily responsibilities (e.g., work, domestic tasks, socialization) comparably to cisgender women (Grandi et al., 2012; Schoep et al., 2019). As participants became increasingly aware of their menstrual symptoms, attempts were made to research online and learn more about their experiences. Previous literature indicated that cisgender women received most of their menstrual education from their mothers first (Aflaq & Jami, 2012; Brantelid et al., 2014; Rembeck et al., 2006) then friends second. On the contrary, the transfeminine participants voiced an overall lack of education on menstruation and identified AFAB (i.e., assigned female at birth) partners and friends as primary source of information regarding menstruation experiences and management.  Menstrual Experiences and Attitudes  Participants reported having received stigmatizing messages about menstruation throughout their lifespan, similar to cisgender women (Johnston-Robledo & Chrisler, 2020; Kowalski & Chapple, 2000; MacLean et al., 2020). However, cisgender women often internalized the negative messages menstruation (Allen et al., 2011; Andrist, Hoyt, et al., 2004; Brantelid et al., 2014) while the transfeminine participants did not. The participants shared their journey in unlearning binary and sex-negative social messages. This process of unlearning social messages is common among TGD people (Berberick, 2020; LeMaster et al., 2019). Nevertheless, the recurrent binary and sex-negative social messages resulted in repeated experiences of invalidation for the participants. These messages are congruent to the queer paradigm’s critiques of the negative impact and role   43  of heteronormative and binary gendered expectations (Marchia & Sommer, 2019; Regan & Meyer, 2021; Semp, 2011).  The invalidating interactions informed the participants’ choice to conceal their experiences of menstrual symptoms. In parallel to transmasculine people who perceived cisgender people having negative or very negative attitudes toward transmasculine people who menstruate (Chrisler et al., 2016), the transfeminine participants communicated careful navigation of conversations with others regarding their menstrual symptoms to avoid invalidating experiences. This process reflects Orne’s (2011) strategic outness model which emphasized careful consideration of social contexts in disclosure of one’s sexuality. In the context of TGD identities, concealment was related to decreased day-to-day experiences of discrimination, but it was also related to lower life satisfaction (Branstorm & Pachankis, 2021) and increased psychological distress (Bockting et al., 2013; Carvalho et al., 2022; Rood et al., 2017). Gender Congruence A large foundation of literature demonstrated cisgender women’s interest in menstruating less (Johnston-Robledo et al., 2003, 2006; Rose et al., 2008) or not at all (Andrist et al., 2004; Fruzzetti et al., 2008) due to the negative impact of menstrual symptoms, and menstrual suppression was an appealing option for many cisgender women as a form of symptom management (Andrist, Hoyt, et al., 2004; Repta & Clarke, 2013). Conversely, participants in the present study maintained that their menstrual symptoms were desirable and voiced their disinterest in menstrual suppression options. The pushback against menstrual suppression for the participants was highly related to their sense of gender congruence.    44  Studies have charted adverse attitudes toward menstruation among transmasculine people due to decreased levels of gender congruence (Cavanaugh & Ladd, 2017; Chrisler et al., 2016; Eisenberg et al., 2021; Frank, 2020). In contrast, Lowik’s (2020) study on reproductive lives suggested that transfeminine people may seek menstruation to support their gender congruence. The transfeminine people in this study continuously expressed that their experiences of a “bloodless period” provided them a sense of “gender euphoria” and corroborated their identity as a woman. Moreover, the participants desired not only for menstrual symptoms but also the capacity to “bleed” and “become pregnant.” Participants explained that pregnancy and birth were linked to the female reproductive system and deeply intertwined with womanhood. Likewise, menstruation was associated with reproductive capacities as the process of menstruation prepared the uterus for possible pregnancy. Both characteristics were desired as they would further solidify their womanhood. Overall, the transfeminine participant’s desire for menstruation strongly contrasting cisgender women’s and transmasculine people’s reason for and practice of menstrual suppression. Implications for Training and Practice  The outcomes of this study may be used as a catalyst for positive social change for transfeminine people. To start, the findings provided evidence for the need to reconceptualize menstruation. Participants were able to challenge the binary and sex-negative social messages and highlighted experiences of menstruation as an all-inclusive experience for people of all genders and not just for people with a uterus. This perspective provides the foundation needed promote trans-inclusive understanding of menstruation, and institutions have begun this movement. For example, based on   45  recommendations by Lane et al., (2021), Columbia University (n.d.) created a handout with guidelines on gender-inclusive language for providers navigating menstrual conversations with TGD people. The American Civil Liberties Union (ACLU; 2019) also developed a menstrual equity toolkit highlighting the importance of gender-inclusive access to menstrual care. However, it is important to note that these resources are centered on the experiences of people assigned female at birth. There is a continued need for conversations surrounding menstruation to transition from a female-centered stance and invite voices of transfeminine people. The inclusion of transfeminine voices is essential as the participants critiqued the absence of overall information and resources available related to menstruation for transfeminine people. It was difficult for the participants to find trustworthy sources and relied on anecdotal experiences of other transfeminine people shared online, which were frequently invalidated by other online forum users and dismissed by healthcare and research professionals. Therefore, a key component of promoting positive social change will require increased access to gender-inclusive resources and support for transfeminine people with menstrual symptoms. In response to the disparities in resources, the current results may also be used to drive important programming for education regarding the presence and management of menstrual symptoms for transfeminine people. The findings may also be used to inform the gender-inclusive practice of mental health and medical providers working with transfeminine people experiencing menstrual symptoms. Studies revealed that access to gender-confirming care was related to increased gender congruence (Owen-Smith et al., 2018; Thoma et al., 2023), positive mental health outcomes, and improved quality of life (Baker et al., 2021; White Hughto & Reisner,   46  2016). Despite these findings, TGD people often faced barriers accessing gender-confirming medical care due to systemic barriers, provider biases, and uninformed care (Puckett et al., 2018). It is critical that mental health and medical providers receive proper education and training to effectively support TGD people and to create access to care and promote positive health outcomes and mitigate risk.  Limitations and Future Directions The main limitation to this study is its generalizability. To start, the eligibility criteria limited the study’s sample to English-speaking transfeminine adults in the United States. For non-English speaking adults, especially those of color, the study’s high level of novelty may have created barriers among those without access to language to understand what a “bloodless period” entailed. Similarly, those who do share the experience of a “bloodless period” may also be limited in their ability to communicate their experiences due to the differences in language used in their culture compared to the study’s language. Additionally, the study’s final sample consisted of all White participants. It is unknown whether transfeminine people of color share similar menstrual symptoms and coping strategies. The messages transfeminine people of color received may have also differed, which may have also informed a different conceptualization of gender and navigation of society as a gendered person. Future research should consider experiences of the “bloodless period” for transfeminine populations of color. Furthermore, all the participants reported current and history of GAHT treatment. The literature has highlighted continued disparities in access to care for people of color over time (Majette, 2003; Himmelstein & Himmelstein, 2020), especially for transgender people of color (Alizaga et al., 2022; Howard et al., 2019; Kattari et al., 2015; Smart et   47  al., 2022). It is possible that limited access to gender-confirming care for transfeminine people may have played a role in diminished reports of menstrual symptoms in this population. In general, there is a need for additional research to guide the creation of gender-inclusive resources and support networks for transfeminine people. The resulting studies may be used to inform transfeminine people of the phenomenon of a “bloodless period” and provide direction to appropriate online and local support networks. The outcomes may also be used to educate healthcare professionals and promote better access to gender-affirming care for transfeminine people. However, the overall relationship between GAHT and menstrual symptoms remains not well understood. This study was unable to recruit participants with no current or history of GAHT treatments for comparison. Likewise, this study primarily focused on the experiences and conceptualization of the menstrual symptoms, rather than the source of the symptoms. The study asked about whether participants currently or historically received GAHT, but participants were not further implored about their GAHT regimen (e.g., daily dosage, frequency of treatment). Therefore, it is unclear whether different types of hormones, dosage, and frequency of treatments informed whether symptoms developed and, if so, what symptoms developed. The findings were also unable to explain the cyclic nature of these symptoms due to this gap in knowledge. Prospective studies should review the influence, if any, of GAHT on menstrual symptoms. Scholars are recommended to take on a collaborative stance to work alongside medical professionals to develop a better understanding of GAHT treatments and their potential impact on TGD people. There is also a need to better understand the cyclicity of the menstrual symptoms, whether they are informed by GAHT or other factors, and whether there are   48  transfeminine people who experience their menstrual symptoms on shorter, longer, or no cyclic patterns.  Another limitation of the study was the high number of bots and fraudulent responses. A variety of security measures were implemented, as discussed above, but the study remained highly susceptible to bots and fraudulent responses. Ultimately, the study came to an end after recruitment and interview of less than a dozen participants. The sample size was adequate for the current study’s methodology (Guest et al., 2006; Moser & Korstjen, 2018; Sim et al., 2018), but it is, overall, a small sample size when considering the absence of current literature on TGD adults’ menstrual experiences and even more for transfeminine adults’ menstrual experiences. This further limited the study’s generalizability. Further research is necessary to better understand the phenomenon of bots and fraudulent responses, its impact on the research community, and improved prevention methods to protect the integrity of future studies.  Finally, the use of the MDQ was another limitation of the study. The MDQ is a questionnaire designed to measure distress related to commonly reported menstrual symptoms. However, the questionnaire was originally created and normed for cisgender women. It is unknown how many of these symptoms are also experienced by transfeminine people and whether the distress level is comparable. However, a measure designed to measure menstrual distress for TGD broadly has yet to be developed and validated, limiting the study to readily available measures of menstrual experiences. Additional research is necessary to create valid and reliable measures of menstrual experience for TGD people. It is recommended that researchers conduct a validation study to assess the validity of currently available menstrual measures for use within the   49  TGD population. Likewise, researchers should also capture whether there are similarities and differences between use of these measure between transmasculine, transfeminine, and non-binary populations. If it is found that the currently available menstrual measures are unreliable and/or invalid for use for TGD populations, additional studies should examine what items related to menstrual symptoms, management, experiences, and attitudes best reflect those of TGD people.  Conclusion As previously noted, to the author’s knowledge, there is no published research focusing on menstruation within the transfeminine population. This is the first study to capture the lived menstrual experiences of transfeminine individuals and the first study to explore the concept of a “bloodless period.” The findings of this study provide an improved understanding of transfeminine people’s positive attitudes toward menstruation and their lived experiences of menstrual symptoms. This study also revealed valuable information regarding the role of interpersonal relationships in cisgender and transmasculine spaces as well as binary and sex-negative social influences, which informed transfeminine people’s conceptualization of and attitudes toward their menstrual symptoms. Finally, the study supplied key details about how menstruation positively supported gender congruence for transfeminine people.      50  References Aflaq, F., & Jami, H. (2012). 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(2019). Hormonal contraceptive choices in a clinic-based series of transgender adolescents and young adults. International Journal of Transgenderism, 20(4), 413–420. https://doi.org/10.1080/15532739.2019.1631929 Kanj, R. V., Conard, L. A. E., & Trotman, G. E. (2016). Menstrual suppression and contraceptive choices in a transgender adolescent and young adult population. Journal of Pediatric and Adolescent Gynecology, 29(2), 201–202. https://doi.org/10.1016/j.jpag.2016.01.100 Kaspersky. (n.d.) What are bots? – Definition and explanation. Kaspersky. https://www.kaspersky.com/resource-center/definitions/what-are-bots  Kattari, S. K., Walls, N. E., Whitfield, D. L., & Langenderfer-Magruder, L. (2015). Racial and ethnic differences in experiences of discrimination in accessing health services among transgender people in the United States. International Journal of Transgenderism, 16(2), 68-79. https://doi.org/10.1080/15532739.2015.1064336 Koutroulis, G. (2001). 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This form tells you more about our study so that you can decide if you want to participate.  What are the main things I should know about this study? ● The reason we are doing this study is to learn more about transfeminine people’s experiences of a bloodless period (i.e., experiencing menstrual-like symptoms without bleeding)  ● Participation in this study is completely voluntary. You do not have to participate in this study, and you may withdraw from the study at any point. ● If you decide to participate in this study, you will be asked to take a short demographic and menstrual symptom questionnaire that will require about 15-20 minutes of your time.  ● If you are interested in the interview portion of the study, you may indicate so at the end of the demographic survey. A small number of people will be contacted by the researcher for a paid, one-hour individual interview to further understand their experiences of a bloodless period.  Purpose: We are a research team of graduate students and faculty at the University of Nebraska-Lincoln, and we are conducting a study on the experiences of the bloodless period by transfeminine adults in the United States.   Why are you doing this research project?  Most research related to menstruation focuses on the experiences of cisgender women. There is limited research on menstruation within the transgender and gender diverse (TGD) community. Furthermore, the limited available research has focused primarily on the experiences of transmasculine and non-binary populations and omits the voices of transfeminine individuals. This will be the first study to capture the lived menstrual experiences of transfeminine individuals, and the first study to explore the concept of a bloodless period.  This study seeks to engage transfeminine voices in a discussion of menstruation by exploring the feminine of the phenomenon of the bloodless period (i.e., experiences of menstrual-like symptoms without bleeding). Specifically, the goal of this study is to understand transfeminine people’s unique experiences of having a bloodless period.   To participate in this study, you must:    72  • Have been assigned male at birth  • Identify as transfeminine (e.g., trans woman, demigirl, non-binary feminine) • Experience menstrual-like symptoms • Be a legal adult (i.e., age of majority within your place of residence) • Live in the United States • Speak English   Procedures: If you choose to participate, you will be asked to complete a short demographic and menstrual symptom questionnaire through Qualtrics, an online survey platform. You will be asked questions, for example, about your race and ethnicity, sexual orientation, education level, relationship status, employment and student status, socioeconomic status, religious or spiritual affiliation, and gender-affirming hormone therapy status. This survey should require between 15-20 minutes of your time.  If you are interested in participating in the interview portion of the study, you will also be prompted to provide your contact information (i.e., email, phone number) along with a pseudonym. The researchers will contact eligible participants to schedule a time for the interview based on the demographic information shared. The researcher aims to take different perspectives into consideration by recruiting a demographically diverse group (e.g., race/ethnicity, age).  Risks and/or Discomforts: You may find it uncomfortable to answer questions about your gender identity and experiences, values, or beliefs about menstruation. You are free to withdraw your consent to participate and may discontinue your participation in the study at any time without consequence. Should you experience emotional discomfort during participation, you are encouraged to visit APA’s Psychologist Locator, https://locator.apa.org, to find a convenient mental health professional from whom you may seek services.    Phone: PFLAG: Numbers vary by location. Please contact your local PFLAG chapter. Trans Lifeline: (877) 565-8860 National Suicide Prevention Lifeline: 988 The Trevor Project (866) 488-7368 LGBT National Hotline:( (888) 842-4564 LGBT National Youth Talk line: (800) 246-7743 Sage LGBT Elder Hotline (888) 234-7243 The National Runaway Safe line: (800) 786-2929  Text: The Trevor Project: Text “Trevor” to (202) 304-1200 Crisis Text: Text “LGBTQ” to 741-741  Online chats: National Suicide Prevention Lifeline: https://suicidepreventionlifeline.org/chat/   73  Laura’s Playground: http://www.lauras-playground.com/transgender_suicide.htm The Trevor Project: https://www.thetrevorproject.org/ LGBT National Hotline: https://www.glbthotline.org/chat.html Trans Teens Online Talk Group: https://www.glbthotline.org/transteens.html   Benefits: Your participation in this research study is voluntary. There are no direct benefits or compensation for your participation in the survey portion of the study. Although you may not directly benefit from participating in this study, we hope that this study will contribute to the understanding of menstrual symptoms among transfeminine people. Your participation is essential to achieving this goal. By participating in this research project, you do not give up any rights or benefits that you are otherwise entitled to and if you choose to not participate, your relationship or future relationships with the University of Nebraska-Lincoln will not be harmed.  Compensation: There is no compensation provided for participating in the survey portion of the study. You will be paid $50.00 in the form of an electronic Tango gift card for your participation in a one-hour interview. Payment will be provided in the form of an electronic Tango gift card delivered via email. Tango is an online platform that allows you to choose where you’d like to redeem your gift card. Please note that compensation will not be provided for interviews that are scheduled but not attended or attended for fewer than 30 minutes. Payment will be provided to all participants at the conclusion of the study (no later than May 2024).    Confidentiality: Reasonable steps will be taken to protect the privacy and the confidentiality of your study data; however, in some circumstances we cannot guarantee absolute privacy and/or confidentiality. The de-identified data will be securely stored electronically through university approved methods for 7 years, after which it will be destroyed, and will only be seen by the research team and/or those authorized to view, access, or use the records during and after the study is complete. Those who will have access to your research records are the study personnel, the Institutional Review Board (IRB), and any other person, agency, or sponsor as required by law or contractor institutional responsibility. The information from this study may be published in scientific journals or presented at scientific meetings and may be reported individually, or as study or summarized data, but your identity will be kept strictly confidential. Deidentified interview transcript(s) will be made available upon request to other researchers via a SharePoint link for the seven years during which the survey data is retained.  Opportunity to Ask Questions: You may ask any questions concerning this research and have those questions answered before agreeing to participate in or during the study. Or you may contact the investigator(s) at the contact information provided below. Please contact the University of Nebraska-Lincoln Institutional Review Board at (402) 472-6965 to voice concerns about the research or if you have any questions about your rights as a research participant.    74    Freedom to Withdraw: Participation in this study is voluntary. You can refuse to participate or withdraw at any time without harming your relationship with the researchers or the University of Nebraska-Lincoln, or in any other way receive a penalty or loss of benefits to which you are otherwise entitled.    Participant Feedback Survey:  The University of Nebraska-Lincoln wants to know about your research experience. These 14 questions, multiple-choice survey is anonymous; however, you can provide your contact information if you want someone to follow-up with you. This survey should be completed after your participation in this research. Please complete this optional online survey at:  https://ssp.qualtrics.com/SE/?SID=SV_aVvlNCf0U1vse5n.    Agreement:  I have read the procedure described above. I am an English-speaking, legal adult (i.e., age of majority within my place of residence) living in the United States. I was assigned male-at-birth, and I currently identify as transfeminine and experience menstrual-like symptoms.  You are voluntarily deciding whether to participate in this research study. By clicking on the “Yes, I consent to participate in the study” button below, your consent to participate is implied. Please save a copy of this informed consent form your records.   Name and Contact Information of Principal Investigator:      Rin Nguyen, Principal Investigator  Department of Educational Psychology    University of Nebraska – Lincoln  Email: knguyen21@huskers.unl.edu   Dena M. Abbott, Co-Investigator  Department of Educational Psychology    University of Nebraska – Lincoln  Email: dabbott5@unl.edu          75  APPENDIX B RECRUITMENT SCRIPTS  Recruitment email  [Subject/Heading]:    Recruiting transfeminine adults for a research study!   [Message Text/Body]:  Hi [NAME OF ORGANIZATION], My name is Rin Nguyen. I am a graduate student at the University of Nebraska-Lincoln. I am conducting an independent study exploring the phenomenon of a bloodless period (i.e., menstrual-like symptoms without bleeding) among transfeminine people. I am reaching out to see if you would be willing to share information about my study. Below is a summary of the study in case you would like to pass the information along.   The study consists of a brief screener survey to determine eligibility for the study. Eligible participants will be asked to take a short demographic questionnaire. The surveys should take between 15-20 minutes to complete. At the end of the demographic questionnaire, participants may indicate their interest in participating in the interview portion of the study and provide contact information. Participants will be compensated with a $50.00 Tango gift card for completion of the one-hour interview. Tango is an online platform that allows participants to choose where they’d like to redeem their gift card to. The results of this study will substantially advance the field’s understanding of menstruation within the TGD population, especially among transfeminine people.   I hope you will consider sharing this study with [NAME OF ORGANIZATION]. I am happy to discuss with you more about the study, my role in the project, and what we hope to come from the findings. Feel free to contact me Rin Nguyen (knguyen21@huskers.unl.edu) with any of your questions. I am also happy to share the findings with you after the study is complete. Below is an IRB approved message. I also attached some flyers as well. _____________________________________________________________________________ [Subject/Heading]:   Recruiting transfeminine adults for a research study!   [Message Text/Body]:  Are you a transfeminine person? Do you experience menstrual-like symptoms? If so, we invite you to participate in our study. In this study, we would like to learn more about your experiences of a bloodless period (i.e., menstrual-like symptoms without bleeding) as a transfeminine person. Participants will receive a $50.00 Tango gift card for completing a one-hour virtual interview. Tango is an online platform that allows participants to choose where they’d like to redeem their gift card to.  To be eligible, you must:     76  • Have been assigned male-at-birth  • Identify as transfeminine (e.g., trans woman, demigirl, non-binary feminine) • Experience menstrual-like symptoms • Be a legal adult (i.e., age of majority within your place of residence) • Live in the United States • Speak English  To participate, please scan the QR code located on the flyer or visit  www.tinyurl.com/BloodlessPeriod   This study has been approved by the Institutional Review Board (IRB) at the University of Nebraska—Lincoln (IRB # 22460). If you have questions, please feel free to contact Rin Nguyen at knguyen21@huskers.unl.edu. Compensation will be provided after data is collected (no later than May 2023).    Scheduling and availability email  [Subject/Heading]:   Invitation to participate in interview    [Message Text/Body]:  Thank you for your interest in participating in an interview to discuss your experiences of a bloodless period (i.e., menstrual-like symptoms without bleeding) as a transfeminine person. To determine the date and time of our meetings, we’d like you to provide your availability at the link below for the weeks of [DATE] and [DATE].    To provide availability, follow these steps:    1. Go to www.when2meet.com[uniqueID].    2. On the left side, under the “Sign in” section, please enter the pseudonym you chose when you consented to participate for “Name.” A password is not necessary, but you can set one if you’d like. 3. On the right side, where the calendar is displayed, please highlight in green all the days and times at which you are available to participate in a one-hour interview.   We will send another email to confirm the date and time of your interview.     Thank you in advance for your participation in our study. If you have questions, please feel free to contact Rin Nguyen at knguyen21@huskers.unl.edu.  Scheduling confirmation email  [Subject/Heading]:   RE: Invitation to participate in interview    [Message Text/Body]:    77  Thank you again for agreeing to participate in an interview to discuss your experiences of a bloodless period (i.e., menstrual-like symptoms without bleeding) as a transfeminine person and for providing your availability. Your interview has been scheduled for:    [DATE AND TIME ]   You will be interviewed by Rin, and you can access the interview via Zoom at this link: [LINK] As a reminder, you chose the pseudonym: [PSEUDONYM]  While you are in the waiting room, please change your visible screen name to a pseudonym. To do so, highlight your name in the waiting room, click more, and choose Rename in the drop-down list.     We also encourage you to engage in the interview in a private place and, if necessary, to use headphones/earbuds to avoid others hearing the content of our call. You may mute your video or withdraw from the call at your discretion.  We look forward to seeing you soon. If you have questions, please feel free to contact Rin Nguyen at knguyen21@huskers.unl.edu.  Compensation email via DocuSign  [Subject/Heading]:   RE: Invitation to participate in interview    [Message Text/Body]:  Thank you for your participation in our study to learn more about the bloodless period (i.e., menstrual-like symptoms without bleeding) among transfeminine people. To provide your compensation, please confirm the email that you’d like to receive your $50.00 electronic Tango gift card at. Tango is an online platform that allows you to choose where you’d like to redeem your gift card.  Please note it may take several weeks following submission of your form to receive your payment. Payment will be provided via email.  Thank you again for your participation in the study. If you have questions, please feel free to contact Rin Nguyen at knguyen21@huskers.unl.edu.          78  APPENDIX C RECRUITMENT FLYER        79  APPENDIX D DATA MANAGEMENT PLAN  Data Management Plan  This plan provides details of plans to preserve and make available data collected during the project period. PI Nguyen and Abbott will be responsible for securing provisions to ensure data are properly managed and archived.  Number and Types of Datasets Expected. Participants will be provided with appropriate consent materials before including their data in the study analyses. Types of data include digital survey responses, audio-video recordings, notes, and interview transcriptions. Data will be collected via a university-sponsored, secure video-conferencing platform (Zoom) and an online survey platform (Qualtrics). The project will generate at least 10 audio-video recordings and interview transcriptions as well as 200 online survey responses. Though the project will also generate audio-video recordings of the interviews, due to the identifiable nature of qualitative data these will not be made publicly available. Likewise, the online survey responses will not be made publicly available due to the identifiable nature of working with a specific marginalized population. Audio-video recordings will be destroyed after data analysis is complete; transcripts will be retained for seven (7) years following the completion of the study.   Commitment to Sharing Data. Data that can be de-identified will be shared following institutional and federal guidelines protecting confidentiality of human subjects. The co-PIs will share de-identified interview transcriptions (PDF format) with other researchers upon request via email. The requester may review the de-identified interview transcripts via the secure, university-sponsored cloud storage (Microsoft SharePoint) link that will be shared.   How Data Will be Handled and Stored During the Project. During the project, any data downloaded from the source (Zoom or Qualtrics) will be stored in secure, university-sponsored cloud storage (Microsoft SharePoint) accessible only by the research team. Audio-video recordings and de-identified transcriptions will be uploaded to the latest version of NVivo, a qualitative data analysis software stored locally on the research team member’s university-provided electronic devices. All devices will have appropriate passwords, firewall, and virus protection. Data will be aggregated for analysis and publication, and no individual will be named or identified in any way in any report or publication.   De-identified interview transcriptions will be stored in the secure, university-sponsored cloud storage (Microsoft SharePoint) in a separate folder. Upon request, a link to the Microsoft SharePoint folder will be provided for access to the de-identified interview transcriptions. Data from the Qualtrics survey and audio-video recordings may not be requested nor paired with the de-identified interview transcriptions to protect the privacy of the participants. At the conclusion of qualitative interviews, 1) participants’ email addresses will be added to an incentive spreadsheet for payment tracking not tied to their   80  data or survey responses and 2) demographic data from participants’ survey responses will be transferred to a separate spreadsheet (“Qualitative Participant Demographics”) wherein their email addresses will be replaced with their pseudonym. All other stored qualitative data (e.g., audio-video recordings, interview transcriptions) will be labeled using pseudonyms.  Plans for Open Storage of Data, Metadata, and Materials Post-Project. PI Nguyen and Abbott will store and share the de-identified interview transcriptions and project information via the host institution's secure data repository (UNLDR; http://dataregistry.unl.edu). De-identified interview transcriptions are allocated a searchable DOI when they are uploaded. De-identified interview transcriptions will be placed in UNLDR after analyses are complete. PI Nguyen will be responsible for long-term decisions regarding the sharing and storage of the data. If PI Nguyen leaves the host institution, data will be made similarly available at the new intuition, if possible, or responsibility will transfer to PI Abbott. The de-identified interview transcriptions will be made publicly available at the time of study publication. When journals offer the option to include data with publications, we will also link the de-identified interview transcriptions with the manuscript.   Open-Access Publishing. The researchers will post private copies of articles on their personal researcher social network page (e.g., ResearchGate) such that articles may be requested and provided at no-cost on an individual basis.   ORCID Identification. Rin Nguyen’s ORCID identifier is: https://orcid.org/0009-0005-4293-2564  Dena Abbott’s ORCID identifier is: https://orcid.org/0000-0002-0295-1796           81  APPENDIX E SCREENER QUESTIONS  1. Do you wish to participate in the study? a. Yes, I consent to participation in this study. b. No, I do not consent to participation in this study.  Skip To: End of Survey If Do you wish to participate in the study? != Yes, I consent to participation in this study.  2. Please complete the CAPTCHA verification below. a. [CAPTCHA verification]  Instructions: Please complete the following screener questions to determine your eligibility for the study.  3. What was your sex assigned at birth (i.e., the sex on your birth certificate)? a. Male at birth b. Female at birth c. Intersex at birth d. Don’t know  Skip To: End of Survey If What was your sex assigned at birth (i.e., the sex on your birth certificate)? != Male at birth  4. Do you identify as transfeminine? Transfeminine is defined as a person who was assigned male at birth and identifies with a gender that is feminine in part or in whole (e.g., trans woman, feminine nonbinary, demigirl, genderfluid with higher femininity).  a. Yes b. No c. Don’t know  Skip To: End of Survey If Do you identify as transfeminine? Transfeminine is defined as a person who was assigned male at b... != Yes  5. Do you currently menstruate or have the capacity to menstruate (i.e., have a period with bleeding)? a. Yes b. No c. Don’t know  Skip To: End of Survey If Do you currently menstruate or have the capacity to menstruate (i.e., have a period with bleeding)? != No    82  6. Do you experience recurring menstrual-like symptoms (e.g., cramping, nausea, tiredness, changes in mood) without bleeding? a. Yes b. No c. Don’t know  Skip To: End of Survey If Do you experience recurring menstrual-like symptoms (e.g., cramping, nausea, tiredness, chan != Yes  7. Are you the legal age of majority in your jurisdiction (i.e., a legal adult)? a. Yes b. No c. Don’t know  Skip To: End of Survey If Are you the legal age of majority in your jurisdiction (i.e., a legal adult)? != Yes  8. What is your current age? Please enter a number. a. [Numerical value]  Skip To: End of Survey If Condition: What is your current age? Is Less Than 18. Skip To: End of Survey.  9. Do you currently live in the United States? a. Yes b. No  Skip To: End of Survey If Do you currently live in the United States? != Yes  10. Do you speak English? a. Yes b. No  Skip To: End of Survey If Do you speak English? != Yes  11. Are you willing to engage in an approximately 60-minute interview with the researchers about your experiences of menstrual-like symptoms without bleeding? a. Yes, I am willing to participate in an interview. b. No, I am not willing to participate in an interview.   Skip To: End of Survey If Are you willing to engage in an approximately 60-minute interview with the researchers about your... = No, I am not willing to participate in an interview.     83  APPENDIX F MENSTRUAL DISTRESS QUESTIONNAIRE (MDQ)  Instructions: The items below describe common symptoms and feelings associated with menstruation. For each item, choose the descriptive category that best describes your experience. That is, for each item, decide whether you have "no experience of symptom", or whether your experience is "present, mild," "present, moderate," "present, strong," or "present, severe." If none of the categories exactly describes your experience, choose one that most closely matches what you feel.  1. Muscle stiffness 2. Headaches 3. Cramps 4. Backache 5. Fatigue 6. General aches and pains  Instructions: The items below describe common symptoms and feelings associated with menstruation. For each item, choose the descriptive category that best describes your experience. That is, for each item, decide whether you have "no experience of symptom", or whether your experience is "present, mild," "present, moderate," "present, strong," or "present, severe." If none of the categories exactly describes your experience, choose one that most closely matches what you feel. 1. Insomnia 2. Forgetfulness 3. Confusion 4. Lowered judgement 5. Difficulty concentrating 6. Distractible 7. Accidents 8. Lowered motor coordination Instructions: The items below describe common symptoms and feelings associated with menstruation. For each item, choose the descriptive category that best describes your experience. That is, for each item, decide whether you have "no experience of symptom", or whether your experience is "present, mild," "present, moderate," "present, strong," or "present, severe." If none of the categories exactly describes your experience, choose one that most closely matches what you feel. 1. Lowered school or work performance 2. Take naps; stay in bed 3. Stay at home 4. Avoid social activities 5. Decreased efficiency  Instructions: The items below describe common symptoms and feelings associated with menstruation. For each item, choose the descriptive category that best describes your   84  experience. That is, for each item, decide whether you have "no experience of symptom", or whether your experience is "present, mild," "present, moderate," "present, strong," or "present, severe." If none of the categories exactly describes your experience, choose one that most closely matches what you feel. 1. Dizziness, faintness 2. Cold sweats 3. Nausea, vomiting 4. Hot flashes Instructions: The items below describe common symptoms and feelings associated with menstruation. For each item, choose the descriptive category that best describes your experience. That is, for each item, decide whether you have "no experience of symptom", or whether your experience is "present, mild," "present, moderate," "present, strong," or "present, severe." If none of the categories exactly describes your experience, choose one that most closely matches what you feel. 1. Weight gain 2. Skin disorders 3. Painful breasts 4. Swelling Instructions: The items below describe common symptoms and feelings associated with menstruation. For each item, choose the descriptive category that best describes your experience. That is, for each item, decide whether you have "no experience of symptom", or whether your experience is "present, mild," "present, moderate," "present, strong," or "present, severe." If none of the categories exactly describes your experience, choose one that most closely matches what you feel. 1. Crying 2. Loneliness 3. Anxiety 4. Restlessness 5. Irritability 6. Mood swings 7. Depression 8. Tension  Instructions: The items below describe common symptoms and feelings associated with menstruation. For each item, choose the descriptive category that best describes your experience. That is, for each item, decide whether you have "no experience of symptom", or whether your experience is "present, mild," "present, moderate," "present, strong," or "present, severe." If none of the categories exactly describes your experience, choose one that most closely matches what you feel. 1. Affectionate 2. Orderliness 3. Excitement 4. Feelings of well-being   85  5. Bursts of energy, activity  Instructions: The items below describe common symptoms and feelings associated with menstruation. For each item, choose the descriptive category that best describes your experience. That is, for each item, decide whether you have "no experience of symptom", or whether your experience is "present, mild," "present, moderate," "present, strong," or "present, severe." If none of the categories exactly describes your experience, choose one that most closely matches what you feel. 1. Feeling of suffocation 2. Chest pains 3. Ringing in the ears 4. Heart pounding 5. Numbness, tingling 6. Blind spots, fuzzy vision            86  APPENDIX G DEMOGRAPHIC QUESTIONNAIRE  Instructions: Please complete the following demographic questionnaire.  1. What best describes your romantic and/or sexual attraction to others? (select all that apply)? a. Heterosexual or straight b. Gay c. Lesbian d. Bisexual e. Pansexual f. Asexual g. Queer h. Questioning i. Don’t know j. An identity not listed (please specify):  k. Prefer not to answer  2. What is your current relationship status? a. Single, never married b. Partnered c. Married d. Divorced e. Separated  f. Widowed g. Don’t know h. Prefer not to answer  3. What best describes your racial and ethnic identity (select all that apply)? a. White b. Black, African American, or Afro-Caribbean c. Native American or Alaskan Native d. Asian or Asian American e. Hispanic or Latinx f. Arab, Middle Eastern or North African g. Native Hawaiian or Pacific Islander h. Don’t know i. An identity not listed (please specify): j. Prefer not to answer   4. Have you ever received hormone replacement therapy (HRT)? a. Yes b. No c. Don’t know d. Prefer not to answer    87  5. Please explain what hormones (e.g., androgen blockers, androgen blockers plus estrogens, etc.) you have received in the past and what form of delivery (e.g., pills, gels, patches, injections, etc.) a. [Text entry]  6. Please provide your best estimate of the last time you received HRT. a. [Text entry]  7. Are you currently receiving hormone replacement therapy (HRT)? a. Yes b. No don’t know c. Prefer not to answer   8. Please explain what hormones (e.g., androgen blockers, androgen blockers plus estrogens, etc.) you are currently receiving and what form of delivery (e.g., pills, gels, patches, injections, etc.) a. [Text box entry]  9. What is the highest degree or level of education you have completed? a. Less than high school b. Some high school, no degree c. High school diploma or GED d. Some college, no degree e. Associate degree (e.g., AA, AS) f. Bachelor’s degree (e.g., BA, BBA, BS) g. Master’s degree (e.g., MA, MS) h. Professional degree (e.g., MD, DDS, JS) i. Doctoral degree (e.g., PhD, EdD) j. Don’t know k. Prefer not to answer   10. What is your current employment status (select all that apply)? a. Not currently working and not looking for work b. Not currently working and looking for work c. Employed full-time d. Employed part-time e. Part-time student f. Pull-time student g. Self-employed h. Retired i. Don’t know j. Prefer not to answer   11. Which of the following best describes your total annual personal income? a. $0 to $9,999  b. $10,000 to $24,999   88  c. $25,000 to $49,999 d. $50,000 to $74,999 e. $75,000 to $99,999 f. $100,000 to $149,999 g. $150,000+  h. Don't know  i. Prefer not to answer   12. Which of the following best describes your total annual household income? a. $0 to $9,999  b. $10,000 to $24,000 c. $25,000 to $49,000 d. $50,000 to $74,999 e. $75,000 to $99,999 f. $100,000 to $149,999 g. $150,000+  h. Don't know i. Prefer not to answer  13. Think of this ladder as representing where people stand in their communities. People define community in different ways; please define it in whatever way is most meaningful to you. At the top of this ladder are the people who have the highest standing in their community. At the bottom are the people who have the lowest standing in their community.  a. Using the numbers next to each step on the ladder, where would you place yourself on this ladder? Think about where you stand at this time in your life, relative to other people in your community. i. [Sliding scale 1-10]  14. Please identify the religions or nonreligions with which you were raised (e.g., the religion or nonreligion your family practiced). (Select all that apply) a. Islam b. Christianity (e.g., Protestant, Catholic, LDS) c. Hinduism d. Buddhism e. Judaism f. Agnostic g. Atheism h. Spiritual, but not religious  i. An identity not listed (please specify):  Display This Question: If Please identify the religions or nonreligions with which you were raised (e.g., the religion or n... = Christianity (e.g., Protestant, Catholic, LDS)    89  15. With which denomination(s) of Christianity were you raised (e.g., your family practiced)? a. Evangelical Protestant   b. Mainline Protestant (e.g., Baptist, Methodist, Lutheran) c. Historically Black Protestant  d. Catholic e. Mormon f. Orthodox Christian  g. Jehovah’s Witness  h. Nothing in particular, but I identify as Christian  i. An identity not listed (please specify):   16. Please identify all religions or nonreligions with which you have identified in your lifetime. (Select all that apply).  a. Islam  b. Christianity (e.g., Protestant, Catholic, LDS)   c. Hinduism   d. Buddhism   e. Judaism   f. Agnosticism  g. Atheism   h. Spiritual, but not religious   i. An identity not listed (please specify):   Display This Question: If Please identify all religions or nonreligions with which you have identified in your lifetime. (S... = Christianity (e.g., Protestant, Catholic, LDS)  17. With which denomination(s) of Christianity have you identified in your lifetime? (Select all that apply) a. Evangelical Protestant   b. Mainline Protestant (e.g., Baptist, Methodist, Lutheran)  c. Historically Black Protestant   d. Catholic  e. Mormon  f. Orthodox Christian   g. Jehovah’s Witness   h. Nothing in particular, but I identify as Christian    i. An identity not listed (please specify):   18. Please identify all religions or nonreligions with which you currently identify (choose all that apply). a. Islam b. Christianity (e.g., Protestant, Catholic, LDS)  c. Hinduism  d. Buddhism     90  e. Judaism  f. Agnosticism   g. Atheism   h. Spiritual, but not religious   i. An identity not listed (please specify):   Display This Question: If Please identify all religions or nonreligions with which you currently identify (choose all that... = Christianity (e.g., Protestant, Catholic, LDS)  19. With which denomination(s) of Christianity do you currently identify? (Select all that apply) a. Evangelical Protestant   b. Mainline Protestant (e.g., Baptist, Methodist, Lutheran)  c. Historically Black Protestant   d. Catholic  e. Mormon  f. Orthodox Christian   g. Jehovah’s Witness   h. Nothing in particular, but I identify as Christian    i. An identity not listed (please specify):    20. Do you identify as a person with a disability, impairment, or other chronic condition? a. Yes   b. No  c. Don't know   21. With which of the following have you been diagnosed? a. Sensory impairment  b. Mobility impairment  c. Learning disorder  d. Mental health disorder  e. An disability, impairment or, chronic condition no listed (please specify):   22. May the researcher contact you to schedule an interview? a. Yes  b. No    Skip To: End of Survey If May the researcher contact you to schedule an interview? != Yes  23. Please enter the email address at which you’d like to be contacted. a. [Text entry]  24. Please enter the phone number at which you’d like to be contacted.   91  a. [Text entry] 25. Please choose a pseudonym (i.e., an alias, a false name) you would like to use for the study. a. [Text entry]      92  APPENDIX H SEMI-STRUCTURED INTERVIEW PROTOCOL   Introduction: Thank you for your participation in the study. My name is Rin Nguyen. I am a second-year doctoral student in the Counseling Psychology program at the University of Nebraska-Lincoln (UNL) working with Dr. Dena Abbott. I identify as a non-binary and menstruating person, and I welcome all pronouns. As part of my master’s thesis research project, I am interviewing transfeminine people like you to learn more about your lived experiences of the “bloodless period” or menstrual-like symptoms in the absence of physical bleeding. The interview will last about one hour, and I will be asking you questions about your experiences with menstrual-like symptoms, your attitudes toward menstruation, and how you think menstruation or menstrual-like symptoms are related to your gender identity. Do you have any questions about me or the study before we start? [Answer any questions the participant may have] As a reminder, this interview will be recorded. The audio recordings will be stored in a UNL secure OneDrive folder and accessed only by the approved research team (e.g., myself, research advisors, and research assistants). Do you consent to me starting the recording for the interview? [If yes] Great, I will now start recording.     Primary research questions  1. How, if at all, do transfeminine people conceptualize and experience their “bloodless periods”?   2. How, if at all, does the presence of menstrual-like symptoms relate to transfeminine people’s sense of gender congruence?    Opening information: I will begin by asking you questions about your experiences as a transfeminine person.    1. Experiences of a feminine identity   a. How would you describe your gender identity?   b. What does it mean to you to be a transfeminine person?  c. How do you define menstruation?    Now I’m going to ask some questions about your experiences with menstrual-like symptoms.    2. Experiences of menstruation   a. What, if any, menstrual-like symptoms do you experience?  i. If symptoms are reported…  1. Tell me about how your menstrual-like symptoms developed.  2. What is it like when you have symptoms?   Opening information: I am now going to ask you questions about messages you’ve received about menstruation and your attitudes toward menstruation.      93  3. Attitudes toward menstruation  a. What messages, if any, have you received about menstruation?  i. From what types of people or settings did you receive these messages?   b. What feelings, if any, do you have about your menstrual-like symptoms?    c. In what ways, if at all, do you find your menstrual-like symptoms desirable?   d. In what ways, if at all, do you find your menstrual-like symptoms challenging?  e. What options, if any, have you considered to suppress your menstrual-like symptoms?    Opening information: I am now going to ask you questions about messages you’ve received about menstruation within the trans community and how menstruation or menstrual-like symptoms are related to your gender identity.    4. Gender congruence   a. What messages, if any, have you received about menstruation within the transgender community?    i. What types of people or settings did you receive these messages from?  b. How, if at all, does your experience of menstrual-like symptoms align with your gender?  c. How, if at all, do you see menstruation or menstrual-like symptoms as being connected or related to womanhood or femininity?   5. Optional questions  a. What else, if anything, might be helpful for you to share with me about your experience of menstrual-like symptoms or menstruation?  b. Were there any questions that I did not ask but should have?  c. What, if anything, about me or the interview today might have made it difficult for you to share your story?  d. Do you know of any other transfeminine people who would be interested in participating in the study? If they are interested in participating in the study, they may contact me at knguyen21@huskers.unl.edu.      Closing statement: Thank you for participating in the study and answering all of my questions today. Your responses will provide a lot of valuable information about the unique lived experiences of transfeminine people and the menstrual-like symptoms of their “bloodless period.” As previously noted, you will be compensated with a $50.00 virtual gift card for your time. You will receive an email with instructions on how to claim your virtual gift card within the next [time frame depends on the timeline of IRB approval and next steps]. Do you have any final questions or comments before we end today? [If yes, respond to the participant's questions and comments] [If no] I will now stop the recording. Thank you again for your participation.

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